Nokea
This patient should be prioritized into which category?
- A. High urgent
- B. Urgent
- C. Non-urgent
- D. Emergent
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?
- A. Decreased breath sounds on the affected side
- B. Hyperresonance on percussion of the affected side
- C. Increased tactile fremitus on the affected side
- D. Tracheal deviation toward the affected side
Correct Answer: A
Rationale: The correct answer is A: Decreased breath sounds on the affected side. In a pleural effusion, fluid accumulates in the pleural space, leading to decreased air entry and diminished breath sounds on auscultation. This occurs because the fluid dampens the transmission of sound through the lungs.
B: Hyperresonance on percussion of the affected side is not expected in pleural effusion, as it is typically associated with conditions like pneumothorax.
C: Increased tactile fremitus on the affected side is not a typical finding in pleural effusion. Tactile fremitus may be decreased due to the presence of fluid.
D: Tracheal deviation toward the affected side is more commonly seen in conditions like tension pneumothorax, not pleural effusion.
Which are collaborative problem statements (select all that apply)?
- A. Fatigue related to sleep deprivation
- B. Infection related to immunosuppression
- C. Excess fluid volume related to high sodium intake
- D. Hypoxia related to chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant.
- B. The infant is very susceptible to infections.
- C. Growth and development patterns will proceed at a normal rate.
- D. Careful monitoring of renal function is indicated.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
- A. Administer albuterol treatment.
- B. Notify Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.
A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
- A. The client is able to ambulate in the hall without dyspnea.
- B. The client has a respiratory rate of 24 breaths per minute.
- C. The client's oxygen saturation is 92%.
- D. The client has a productive cough.
Correct Answer: A
Rationale: The correct answer is A because the ability to ambulate without dyspnea indicates effective oxygen therapy. When a client can move without experiencing difficulty breathing, it suggests that the oxygen therapy is adequately supporting their oxygenation needs. In contrast, options B, C, and D do not directly indicate the effectiveness of oxygen therapy. Option B (respiratory rate of 24 breaths per minute) may be within normal range but does not confirm the therapy's efficacy. Option C (oxygen saturation of 92%) is below the desired range of 95-100%, indicating inadequate oxygenation. Option D (productive cough) is unrelated to the assessment of oxygen therapy effectiveness.