Nokea
What nursing action is most appropriate when administering both types of oral medication to this client?
- A. Administer the cough syrup first, then the tablets.
- B. Wait 15 minutes after giving the cough syrup before giving the tablets.
- C. Give the cough syrup between administering the tablets.
- D. Administer the tablets first, then the cough syrup.
Correct Answer: D
Rationale: Administering tablets first ensures they are swallowed properly, followed by the cough syrup, which may coat the throat and aid swallowing.
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Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.
The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement?
- A. Discuss implementing an advance directive.
- B. Explain the use of chemotherapy for brain involvement.
- C. Teach the client to discontinue driving.
- D. Have the significant other make decisions for the client.
Correct Answer: C
Rationale: Brain metastasis impairs cognition, making driving unsafe (C). Advance directives (A), chemotherapy (B), and proxy decisions (D) are secondary or inappropriate.
When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
- A. The most difficult time of the day for me is the first hour after waking up in the morning.'
- B. I feel best in the morning after a good night's sleep.'
- C. I seem to have more energy after eating a big meal.'
- D. I don't know why, but I get my 'second wind' at night and don't want to go to bed.'
Correct Answer: A
Rationale: Morning fatigue is common in COPD due to mucus accumulation and poor sleep, affecting activity tolerance.
Which clinical manifestation would the nurse assess in the client newly diagnosed with intrinsic lung cancer?
- A. Dysphagia.
- B. Foul-smelling breath.
- C. Hoarseness.
- D. Weight loss.
Correct Answer: C
Rationale: Hoarseness (C) is a common early symptom of intrinsic lung cancer due to tumor compression of the recurrent laryngeal nerve. Dysphagia (A) is more typical of esophageal involvement. Foul-smelling breath (B) is non-specific. Weight loss (D) occurs later in advanced disease.