Nokea
The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of
- A. agreeing to discontinue smoking.
- B. ambulating 50 feet without experiencing dyspnea.
- C. experiencing no dyspnea on exertion.
- D. tolerating activity well.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What condition could predispose a client to shock?
- A. The kidneys work improperly
- B. The heart fails as an effective pump
- C. Peripheral blood vessels massively constrict
- D. Blood volume increases
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications.
A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease.
B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action.
C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.
What is the initial management for a foreign body in the eye?
- A. Irrigation
- B. Surgical removal
- C. Topical antibiotics
- D. Observation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while withdrawing the catheter
- B. Preoxygenating the client before suctioning
- C. Suctioning up to three times if necessary
- D. Suctioning for a duration of 10 to 15 seconds each time
Correct Answer: A
Rationale: The correct answer is A. When suctioning a tracheostomy, the student should not apply suction while withdrawing the catheter to prevent mucosal damage. The correct technique involves inserting the catheter without applying suction, then withdrawing it while applying suction. This helps to clear secretions effectively without causing trauma. Choices B, C, and D are incorrect. Preoxygenating the client is a recommended practice to prevent hypoxemia during suctioning. Suctioning up to three times if necessary and suctioning for 10-15 seconds each time are appropriate techniques to clear secretions effectively without causing harm.