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What is your evaluation of Mr. Jackson’s situation with continuing dyspnea, chest pain, and low-grade fever?
- A. Bacteria-infected fluid is reaccumulating
- B. This is the usual course of the disease
- C. His condition is worsening
- D. A repeat thoracentesis should be performed
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)
- A. Administer prescribed albuterol (Ventolin) inhaler.
- B. Assess the client for tracheal deviation.
- C. Administer oxygen to maintain saturations greater than 94%.
- D. Perform peak expiratory flow measurements.
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Administer oxygen to maintain saturations greater than 94%):
1. Oxygen is crucial in managing asthma exacerbations to improve oxygen saturation levels and prevent hypoxemia.
2. Decreased pulse oxygen saturation indicates hypoxemia, which can lead to serious complications.
3. Maintaining saturations greater than 94% ensures adequate oxygenation of tissues and organs.
4. Administering oxygen promptly can help alleviate respiratory distress and improve the client's condition.
Summary of why other choices are incorrect:
- Choice A (Administer albuterol inhaler): While albuterol is a common medication for asthma, oxygen therapy is the priority in this scenario to address hypoxemia.
- Choice B (Assess for tracheal deviation): Tracheal deviation is not typically associated with asthma exacerbations and is not the most urgent action needed in this situation.
- Choice D (Perform peak expiratory flow measurements): Peak expiratory flow
It is important to teach a patient who is receiving immunosuppressive therapy for a bone marrow transplant to
- A. Avoid other people with signs of infection.
- B. Report signs of infection, such as sore throat or fever.
- C. Take the medications as directed.
- D. All of the above.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which phase of the nurse-client relationship demonstrates a plan constructed mutually to meet goals identified during the assessment of the client?
- A. Termination phase
- B. Working phase
- C. Introductory phase
- D. Transition phase
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While discussing factors causing emphysema with Mr. Puff, what major factor is he already aware of?
- A. Air pollution
- B. Repeated bronchial infections
- C. Cigarette smoking
- D. Hereditary
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?
- A. Shake the inhaler well before use.
- B. Inhale rapidly while administering the medication.
- C. Administer the medication while lying down.
- D. Hold the inhaler 2 inches away from the mouth while inhaling.
Correct Answer: A
Rationale: Rationale for Correct Answer A:
1. Shaking the inhaler well before use helps ensure proper mixing of the medication.
2. This action helps to distribute the medication evenly for effective delivery.
3. It prevents clogging and ensures the client receives the correct dose.
4. Shake-and-use approach is essential for optimal therapeutic benefits.
Summary of Incorrect Choices:
B: Inhaling rapidly may lead to improper medication delivery and increase the risk of side effects.
C: Administering medication while lying down may not allow the client to inhale the medication effectively.
D: Holding the inhaler too far away can result in decreased medication intake and reduced efficacy.