Nokea
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night
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The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
- A. Rely on child's self-report
- B. Use a peak-flow meter
- C. Note skin color changes
- D. Monitor pulse rate
Correct Answer: B
Rationale: The peak flow meter, if used correctly, shows effectiveness of inhalants.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth
- B. Blurred vision and eye pain
- C. Occasional cough
- D. Mild nasal congestion
Correct Answer: B
Rationale: Blurred vision and eye pain suggest acute angle-closure glaucoma, a rare but serious ipratropium side effect. Options A, C, and D are less urgent: dry mouth is common, cough is expected, and congestion is nonspecific.
A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem