Nokea
What is an infection that causes inflammation in the air sacs of one or both lungs, which may fill with fluid or pus?
- A. Pneumonia
- B. Tuberculosis
- C. Pleurisy
- D. Pulmonary edema
Correct Answer: A
Rationale: The correct answer is A: Pneumonia. Pneumonia is an infection that causes inflammation in the air sacs of the lungs, leading to fluid or pus accumulation. This is a common respiratory condition characterized by symptoms such as cough, fever, and difficulty breathing. Pleurisy (C) is inflammation of the pleura surrounding the lungs, not the air sacs. Tuberculosis (B) is a bacterial infection affecting the lungs but does not specifically mention inflammation and pus in the air sacs. Pulmonary edema (D) is the accumulation of fluid in the lungs but is not caused by an infection like pneumonia.
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What is a chronic condition where the airways in the lungs become damaged and widened, leading to mucus buildup and frequent infections?
- A. Bronchiectasis
- B. Chronic bronchitis
- C. Pneumoconiosis
- D. Asthma
Correct Answer: A
Rationale: The correct answer is A: Bronchiectasis. This condition involves permanent widening and damage to the airways, leading to mucus accumulation and recurrent infections. Chronic bronchitis (B) primarily involves inflammation of the bronchial tubes without permanent widening. Pneumoconiosis (C) is a group of lung diseases caused by inhaling mineral dust, not directly related to airway damage. Asthma (D) is characterized by reversible airway constriction and inflammation, not permanent widening like in bronchiectasis.
In developing a plan of care in relation to Mr. Robertson's diuretic therapy, it would be most important to
- A. Monitor vital signs frequently
- B. Give the Lasix with milk
- C. Observe for fluid overload
- D. Observe for signs of hypokalemia
Correct Answer: D
Rationale: Hypokalemia is a common side effect of diuretics.
A patient with chronic heart failure is treated with hydrochlorothiazide, digoxin, and lisinopril. To prevent the risk of digitalis toxicity with these drugs, it is most important that the nurse monitor the patient's
- A. HR
- B. BP
- C. Potassium levels
- D. GI function
Correct Answer: C
Rationale: Hypokalemia is one of the most common causes of digitalis toxicity. When a patient is receiving potassium losing diuretics, such as hydrochlorothiazide and furosemide, it is essential to monitor the potassium level.
The client is being taught about the use of warfarin. What is the most important dietary instruction?
- A. Avoid foods high in vitamin K.
- B. Increase the intake of vitamin K-rich foods.
- C. Avoid foods high in protein.
- D. Increase the intake of foods high in calcium.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K can interfere with the effectiveness of warfarin. By avoiding these foods, the client can maintain consistent levels of the medication in their system.
Choice B is incorrect as increasing vitamin K-rich foods can counteract the effects of warfarin. Choice C is incorrect as there is no need to avoid foods high in protein when taking warfarin. Choice D is incorrect as increasing calcium intake does not have a direct impact on warfarin therapy.
The client on nitroglycerin patches reports dizziness when standing up. What is the nurse's best response?
- A. Advise the client to rise slowly to prevent dizziness.
- B. Instruct the client to discontinue the nitroglycerin patches.
- C. Encourage the client to rest and avoid physical activity.
- D. Suggest the client take an over-the-counter antiemetic.
Correct Answer: A
Rationale: The correct response is A: Advise the client to rise slowly to prevent dizziness. Nitroglycerin patches can cause orthostatic hypotension, leading to dizziness when standing up quickly. By advising the client to rise slowly, the nurse can help prevent a sudden drop in blood pressure and reduce the risk of dizziness and falls. This response promotes client safety and addresses the underlying cause of the symptom.
Choices B, C, and D are incorrect:
B: Instructing the client to discontinue nitroglycerin patches is not appropriate without consulting the healthcare provider. Abruptly stopping nitroglycerin can lead to serious complications.
C: Encouraging the client to rest and avoid physical activity does not address the issue of orthostatic hypotension caused by nitroglycerin patches.
D: Suggesting an over-the-counter antiemetic is not indicated for dizziness related to orthostatic hypotension. It does not address the underlying cause