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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 (aerosols), mobilize mucus (percussion), and clear secretions (postural drainage) to improve breathing in cystic fibrosis.
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A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase (typically >3 times normal) is a key diagnostic marker for acute pancreatitis due to pancreatic enzyme leakage. The other findings are nonspecific or normal.
Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?
- A. Prevent the influx of calcium into cells.
- B. Restore a normal blood pressure reading.
- C. Prevent the inflammatory process.
- D. Dissolve the clot that has formed.
Correct Answer: A
Rationale: Nimodipine, a calcium channel blocker, prevents calcium influx into cells, reducing vasospasm post-aneurysm rupture. It doesn’t normalize BP (B), prevent inflammation (C), or dissolve clots (D).
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
- A. Weight gain
- B. Hair loss
- C. Sore throat
- D. Brittle nails
Correct Answer: C
Rationale: Pulmozyme, used to thin mucus in cystic fibrosis, can cause sore throat as a side effect due to inhalation irritation. Weight gain, hair loss, and brittle nails are not associated.
A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:
- A. Monitoring for recurrence
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.