Nokea
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (via aerosols) and mobilize thick mucus (via percussion and drainage) to improve breathing in cystic fibrosis.
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A primigravida with(choices truncated due to document error; assuming standard options for context) diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours as needed prn for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic that can exacerbate maternal diabetes by causing hyperglycemia, so this order should be questioned in a diabetic primigravida.
When administering a tuberculin skin test, the nurse should insert the needle at a:
- A. 15° angle
- B. 30° angle
- C. 45° angle
- D. 90° angle
Correct Answer: A
Rationale: A 15° angle is used for intradermal injections like the tuberculin skin test to ensure proper placement in the dermis.
The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?
- A. Arterial blood gas POâ‚‚ of 98
- B. Increase in lethargy
- C. Pupils slow to react to light
- D. Temperature of 101°F
Correct Answer: A
Rationale: An arterial blood gas POâ‚‚ of 98 indicates adequate oxygenation, supporting cerebral perfusion, which is a favorable outcome for a subdural hematoma.
The nurse on the inpatient memory care unit is caring for a client with Alzheimer's who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions?
- A. notify the family
- B. notify security along with a description of the client
- C. ask the observer in what direction the client headed
- D. ask other staff on the unit to assist in finding the client
Correct Answer: B
Rationale: Notifying security with a description ensures a rapid, coordinated response to locate the client and ensure safety.
Following surgical repair of a fractured femur, a client's hemoglobin falls to 7.4 and the physician orders one unit of packed red blood cells (250 mL) to be administered over two hours with a drop factor of 10 drops/mL. What flow rate (drops per minute) is needed? Record by rounding to the nearest whole number.
Correct Answer: 21
Rationale: To calculate the flow rate: (Volume X Drop factor)/ Time in minutes. Volume is 250 mL, drop factor is 10 drops/mL, time is 2 hours = 120 minutes. Thus, (250 X 10)/ 120 = 2,500/ 120 ≈ 20.83, rounded to 21 drops/minute.