Nokea
Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct Answer: A
Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.
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What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.
A healthcare professional is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information?
- A. Disease registry.
- B. Department of Health.
- C. Bureau of Vital Statistics.
- D. Census data.
Correct Answer: C
Rationale: The correct answer is C: Bureau of Vital Statistics. The Bureau of Vital Statistics is responsible for maintaining records on births, deaths, and other vital events in a particular region. Therefore, it is the most likely state resource to provide information on infant death rates. Disease registry (A) typically focuses on specific diseases rather than overall mortality rates. Department of Health (B) may have some data but may not specifically focus on vital statistics. Census data (D) provides population demographics but does not specifically track infant death rates.
What instruction should be provided to a client with a history of myocardial infarction (MI) who is prescribed nitroglycerin?
- A. Take nitroglycerin with food to avoid stomach upset.
- B. Store nitroglycerin tablets in a dark, glass container.
- C. Swallow nitroglycerin tablets whole without chewing.
- D. Discontinue the medication if a headache occurs.
Correct Answer: B
Rationale: The correct answer is B because nitroglycerin tablets should be stored in a dark, glass container to protect them from light and moisture, which could decrease their effectiveness. Storing them in any other container could lead to degradation of the medication.
Choice A is incorrect because nitroglycerin should be taken sublingually, not with food. Choice C is incorrect because nitroglycerin should be placed under the tongue to be absorbed quickly, not swallowed whole. Choice D is incorrect because experiencing a headache is a common side effect of nitroglycerin and does not indicate that the medication should be discontinued.
The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?
- A. Weigh the child daily.
- B. Observe the lower extremities for pitting edema.
- C. Measure the child's abdominal girth weekly.
- D. Weigh the child's wet diapers.
Correct Answer: A
Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is the most accurate way to determine fluid retention in a child with nephrotic syndrome as it provides real-time data on fluid status. Weight gain is a key indicator of fluid retention in these patients. Observing lower extremities for pitting edema (B) is subjective and may not accurately reflect fluid status. Measuring abdominal girth weekly (C) may not provide timely information on fluid retention. Weighing wet diapers (D) does not give a comprehensive picture of total fluid retention and may not be as accurate as daily weight monitoring.