Nokea
What are the priority medical interventions for a client experiencing shock?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
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In assisting clients with vertigo and balance problems, which team members (RN, LPN/LVN, MD, physical therapist, nursing assistant), working under appropriate supervision, should be assigned to fulfill each task?
- A. Assess and identify the etiology of vertigo.
- B. Assist the client in routine position change and ambulation.
- C. Administer antivertigo agents, such as meclizine (Antivert).
- D. Obtain informed consent for a labyrinthectomy.
Correct Answer: A
Rationale: Assessment and identification of the etiology of vertigo require advanced clinical judgment, making this task appropriate for an RN or MD.
A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?
- A. Restrict the client's fluid intake to less than 2 L/day
- B. Provide the client with a low-protein diet
- C. Have the client use the early-morning hours for exercise and activity
- D. Instruct the client to use pursed-lip breathing
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and decrease air trapping in clients with COPD, enhancing oxygenation and reducing shortness of breath. It also facilitates better gas exchange and can help the client manage their symptoms effectively.
A: Restricting fluid intake is not typically indicated for clients with COPD unless they have comorbid conditions that require fluid restriction.
B: Providing a low-protein diet is not a standard intervention for COPD management. Protein is important for muscle strength and repair in these clients.
C: While exercise and activity are beneficial for clients with COPD, instructing them to do so specifically in the early-morning hours is not a priority intervention compared to pursed-lip breathing.
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?
- A. Pigeon
- B. Funnel
- C. Kyphotic
- D. Barrel
Correct Answer: D
Rationale: The correct answer is D: Barrel. In COPD, the chest becomes barrel-shaped due to hyperinflation of the lungs. This results in an increased anterior-posterior chest diameter, giving it a rounded appearance. This shape is characteristic of COPD as the hyperinflation causes the rib cage to remain partially expanded at all times.
A: Pigeon – This shape is not associated with COPD and is not a typical finding in respiratory conditions.
B: Funnel – This shape is not associated with COPD and is more commonly seen in conditions like pectus excavatum.
C: Kyphotic – This shape refers to an exaggerated outward curvature of the thoracic spine, not the chest shape itself.
What is the treatment for viral conjunctivitis?
- A. Antibiotic drops
- B. Steroid drops
- C. Supportive care
- D. Surgical intervention
Correct Answer: C
Rationale: Viral conjunctivitis typically resolves with supportive care, such as artificial tears and cold compresses.
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
- A. Direct sunlight
- B. Foods containing tyramine
- C. Foods fermented with yeast
- D. Canned citrus fruit drinks
Correct Answer: A
Rationale: Chlorpromazine increases photosensitivity, so direct sunlight should be avoided.