Nokea
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.
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A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
- A. Hypoxia, shortness of breath, and exertional fatigue
- B. Weight loss, increased RBC, and fever
- C. Rales, edema, and enlarged spleen
- D. Edema of the lower extremities and distended neck veins
Correct Answer: D
Rationale: Cor pulmonale, right heart failure from lung disease, causes lower extremity edema and distended neck veins due to increased venous pressure. Hypoxia and fatigue are general emphysema symptoms.
The nurse is caring for a client with a history of atrial fibrillation. Which medication is most likely to be prescribed to prevent thromboembolism?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Clopidogrel (Plavix)
- D. Heparin
Correct Answer: A
Rationale: Warfarin is commonly prescribed for atrial fibrillation to prevent thromboembolism by maintaining anticoagulation (target INR 2–3). Aspirin and clopidogrel are less effective, and heparin is used short-term.
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is:
- A. The degree of pulmonary involvement
- B. The ability to maintain an ideal weight
Correct Answer: A
Rationale: Pulmonary involvement is the primary determinant of prognosis in cystic fibrosis, as progressive lung disease is the leading cause of morbidity and mortality.
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Hypotension
- B. Photosensitivity
- C. Excessive appetite
- D. Dryness of the mouth
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Advise the mother not to give her aspirin
- B. Ask if the client is allergic to aspirin before giving further information
- C. Assess the function of the client's cranial nerve VIII
- D. Check the aspirin bottle label to determine milligrams per tablet
Correct Answer: A
Rationale: Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. Allergy to aspirin is not related to Reye's syndrome. Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. A 6-year-old child should not be given any baby aspirin.