Nokea
Two hours after arriving on the medical-surgical unit, the client develops dyspnea. SaO2 is 91%, and the client is exhibiting audible wheezing and use of accessory muscles. Which of the following medications should the nurse expect to administer?
- A. Antibiotic
- B. Beta-blocker
- C. Antiviral
- D. Beta2 agonist D.The nurse should expect to administer a beta2 agonist. Beta2 agonists are used for relief of acute symptoms. Neither an antibiotic, an antiviral, nor a beta blocker are indicated for this condition. of the following to guide interpretation of severity of findings?
Correct Answer: D
Rationale: In this situation, the client is experiencing dyspnea, audible wheezing, and decreased oxygen saturation, indicating the presence of respiratory distress, likely due to bronchoconstriction. These are classic symptoms of an acute asthma exacerbation or an obstructive respiratory condition. Beta2 agonists, such as albuterol, are bronchodilators that work by relaxing the muscles in the airways, relieving bronchoconstriction and improving airflow. Administering a beta2 agonist promptly is crucial to provide relief and improve the client's respiratory status. Antibiotics, antivirals, and beta-blockers are not appropriate treatments for acute bronchoconstriction or asthma exacerbation.
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A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
- A. Immediately
- B. 2 to 3 weeks
- C. 1 week
- D. 1 month
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse reaction to chlorambucil, which typically occurs within 2 to 3 weeks of starting treatment. This is because chemotherapy drugs like chlorambucil target rapidly dividing cells, which also includes hair follicles leading to hair loss. Patients should be informed about this potential side effect so that they can be prepared for it and explore options like wearing wigs or scarves if they wish.
The activation of B cells in humoral immunity is assisted by which of the following?
- A. Cytotoxic T cells
- B. Suppressor T cells
- C. Helper T cells
- D. Neutrophils
Correct Answer: C
Rationale: In humoral immunity, the activation of B cells is facilitated by helper T cells. Helper T cells play a crucial role in coordinating the immune response by interacting with B cells. They secrete cytokines that stimulate B cells to proliferate and differentiate into antibody-secreting plasma cells. Without the assistance of helper T cells, the activation of B cells and the production of antibodies would be impaired. Cytotoxic T cells are involved in cell-mediated immunity, supressor T cells regulate immune response, and neutrophils are involved in phagocytosis and innate immunity, but they do not directly assist in B cell activation in humoral immunity.
A nurse plans therapeutic play time for a hospitalized child. What are the benefits of play? (Select all that apply.)
- A. Serves as method to assist disturbed children
- B. Allows the child to express feelings
- C. The nurse can gain insight into the child's feelings.
- D. The child can deal with concerns and feelings.
Correct Answer: A
Rationale: Play serves as a method to assist disturbed children by providing them with a therapeutic outlet to express themselves and work through their emotions in a safe and constructive manner.
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient's jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.
The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?
- A. Ask her, "Are you sexually active?"
- B. Ask her, "Are you having sex with anyone?"
- C. Ask her, "Are you having sex with a boyfriend?"
- D. Ask both the girl and her parent whether she is sexually active.
Correct Answer: A
Rationale: The best way to determine whether an adolescent girl is sexually active is to ask her directly, "Are you sexually active?" This question is concise, clear, and non-judgmental, allowing the girl to provide a straightforward answer. It is important to create a safe and open environment for discussing sexual health, and using direct language helps ensure accurate communication. Asking about specific partners (options B and C) may lead to confusion or misinterpretation, and involving the parent (option D) without the girl's consent may violate her privacy and autonomy. Therefore, direct communication with the adolescent herself is the most appropriate approach to gather information about her sexual activity.