Nokea
When the physician prescribes the first-generation antihistamine for the client's symptomatic relief, the nurse appropriately advises the client that first-generation antihistamines are associated with which side effect?
- A. Weight loss
- B. Constipation
- C. Drowsiness
- D. Depression
Correct Answer: C
Rationale: First-generation antihistamines cross the blood-brain barrier, often causing drowsiness as a common side effect.
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A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: Active tuberculosis requires airborne precautions due to its transmission via respiratory droplets. A respirator (e.g., N95) is required for healthcare workers, not a surgical mask, to protect against inhaling the bacteria.
The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?
- A. Cool extremity
- B. Decreases pulses
- C. Redness
- D. Pain
- E. Warm extremity
- F. Swelling
- G. Cyanosis
Correct Answer: C,D,E,F
Rationale: Signs and symptoms of a DVT include: redness, swelling, warm extremity, pain, positive Homan's Sign, and swelling (which can be unilateral...meaning there is more swelling in one extremity compared to the other).
The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention?
- A. ABG results of pH 7.35, Paco2 56, Hco3 29, Pao2 78 for a client diagnosed with COPD.
- B. Pulse oximetry reading of 89% on a two-day postsurgical total knee replacement client.
- C. Hgb of 9 g/dL and Hct of 28% on a client who is receiving the second unit of blood.
- D. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.
Correct Answer: B
Rationale: SpO2 89% post
When the client asks the nurse about why the physician has prescribed two drugs, which response is most accurate?
- A. One medication diminishes the side effects of the other.
- B. One medication kills the live organism; the other, its spores.
- C. Using combined medications can reduce the dosages of both drugs.
- D. Using two or more drugs lowers the potential for bacterial resistance.
Correct Answer: D
Rationale: Combination therapy (rifampin and isoniazid) reduces the risk of bacterial resistance, ensuring effective tuberculosis treatment.
Which pulse oximetry reading indicates to the nurse that the client has normal tissue oxygenation?
- A. 80 to 90 mm Hg
- B. 95 to 100 mm Hg
- C. 80% to 85%
- D. 95% to 100%
Correct Answer: D
Rationale: A pulse oximetry reading of 95% to 100% indicates normal tissue oxygenation, reflecting adequate oxygen saturation.