Nokea
What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?
- A. Autoimmune disease
- B. Infectious disease
- C. Allergic reaction
- D. Degenerative disease
Correct Answer: A
Rationale: The correct answer is A: Autoimmune disease. In autoimmune diseases, the immune system mistakenly attacks the body's tissues, leading to inflammation and damage. This occurs due to a breakdown in immune tolerance, resulting in the immune system targeting self-antigens. This leads to chronic inflammation and tissue damage. In contrast, infectious diseases are caused by pathogens, allergic reactions are responses to harmless substances, and degenerative diseases involve the gradual deterioration of tissues over time. Therefore, autoimmune disease best fits the description provided in the question.
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What is a condition where the alveoli are gradually destroyed, leading to shortness of breath and reduced oxygen exchange?
- A. Emphysema
- B. Pulmonary fibrosis
- C. Pulmonary edema
- D. Lung cancer
Correct Answer: A
Rationale: Emphysema is the correct answer. Alveoli destruction in emphysema leads to shortness of breath and reduced oxygen exchange. This condition is primarily caused by smoking and results in irreversible damage to the air sacs in the lungs. Pulmonary fibrosis involves scarring of lung tissue, not alveoli destruction. Pulmonary edema is fluid accumulation in the lungs, disrupting oxygen exchange. Lung cancer is the uncontrolled growth of abnormal cells in the lung, which may not directly lead to alveoli destruction.
The client has a prescription for sublingual nitroglycerin. What is the nurse's instruction for how to take this medication during an episode of chest pain?
- A. Take one tablet every 5 minutes, up to three tablets.
- B. Take one tablet every hour until the pain subsides.
- C. Take two tablets immediately if chest pain occurs.
- D. Take one tablet with a full glass of water.
Correct Answer: A
Rationale: The correct answer is A. Sublingual nitroglycerin is taken under the tongue to quickly relieve chest pain. The nurse should instruct the client to take one tablet every 5 minutes during an episode of chest pain, up to a maximum of three tablets. This is because nitroglycerin works rapidly to dilate blood vessels and improve blood flow to the heart, helping to relieve angina symptoms. Taking one tablet every hour or two tablets immediately may not provide adequate relief and could lead to an overdose. Taking the tablet with water is unnecessary as the medication is absorbed through the mucous membranes under the tongue.
The client is receiving digoxin and complains of nausea. What is the nurse's priority action?
- A. Check the client's digoxin level.
- B. Continue the current dose of digoxin.
- C. Administer an antiemetic for nausea.
- D. Discontinue the digoxin immediately.
Correct Answer: A
Rationale: The correct answer is A: Check the client's digoxin level. The priority action is to assess the digoxin level to determine if it is within the therapeutic range, as nausea can be a sign of digoxin toxicity. Checking the level will guide further actions. Continuing the dose without assessment (B) may worsen toxicity. Administering an antiemetic (C) only addresses the symptom, not the underlying cause. Discontinuing digoxin immediately (D) without assessing the level can be harmful if the client actually needs the medication.
Receiving a report that Mr. K.'s prothrombin time (PT) is 4-4.5 times normal, your nursing action would be to
- A. call Mr. K.'s physician to report the PT
- B. stop the heparin infusion
- C. increase the heparin infusion by 10 mg/hr
- D. nothing, as the value is therapeutic
Correct Answer: A
Rationale: An elevated PT indicates potential bleeding risk, necessitating immediate medical review.
In Mrs. Jones' discharge teaching with a permanent pacemaker, which point should be covered?
- A. She should not get pregnant because her heart would not be able to tolerate the increased workload
- B. She should not exercise regularly
- C. She can return to the degree of sexual activity that is desired and tolerable for her
- D. It is not necessary to make a return visit to her physician
Correct Answer: C
Rationale: Sexual activity can generally continue with appropriate precautions.