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A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
- A. Do you have trouble affording your medications?
- B. Most people with hypertension do not have symptoms.
- C. You are lucky; most people get severe morning headaches.
- D. You need to take your medicine or you will get kidney failure.
Correct Answer: B
Rationale: Step-by-step rationale:
1. Choice B is correct because it educates the client that hypertension often presents without symptoms.
2. Lack of symptoms does not mean the condition is not serious.
3. This response promotes understanding and adherence to medication.
4. Choices A, C, and D are incorrect as they do not address the main issue of hypertension being asymptomatic.
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A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply)
- A. I held the client's morning bronchodilator medication.
- B. The client is ready to go down to radiology for this examination.
- C. Physical therapy states the client can run on a treadmill.
- D. I advised the client not to smoke for 6 hours prior to the test.
Correct Answer: B
Rationale: The correct answer is B because it communicates important information to the respiratory therapist regarding the client's readiness for the PFTs. Going down to radiology indicates the client is prepared for the examination, which ensures the test can be conducted smoothly.
Rationale:
A: Holding the client's morning bronchodilator medication may impact test results, but this information is more relevant for the healthcare provider interpreting the results, not the respiratory therapist conducting the test.
C: Physical therapy's statement about running on a treadmill is irrelevant to the PFTs and does not impact the collaboration between the nurse and respiratory therapist.
D: Advising the client not to smoke for 6 hours prior to the test is important for accurate results, but this information is more pertinent for the client and healthcare provider interpreting the results, not the respiratory therapist conducting the test.
What educational information related to nutrition would you provide to a client with anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which biological agent has a vaccine readily available but is only used for military and at-risk civilians?
- A. Botulism
- B. Anthrax
- C. Smallpox
- D. Influenza
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements.
- B. Potential complication hemorrhage.
- C. Ineffective individual coping.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.