Nokea
Which is an inappropriate item in planning care for a severely neutropenic client?
- A. Transfuse neutrophils
- B. Exclude raw vegetables
- C. Avoid rectal suppositories
- D. Prohibit vases of fresh flowers
Correct Answer: A
Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.
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A nurse is caring for a patient who is post-operative following a lung resection. The nurse should monitor for which of the following signs of complications?
- A. Increased respiratory rate and dyspnea.
- B. Constipation and abdominal distension.
- C. Nausea and vomiting.
- D. Muscle weakness and fatigue.
Correct Answer: A
Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early.
Incorrect choices:
B: Constipation and abdominal distension are not directly related to post-operative lung resection complications.
C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection.
D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.
A nurse is caring for a patient who has had a myocardial infarction. Which of the following medications should the nurse expect to be prescribed for this patient?
- A. Lisinopril.
- B. Acetaminophen.
- C. Furosemide.
- D. Hydrochlorothiazide.
Correct Answer: A
Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage.
Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function.
Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI.
Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI.
Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI.
Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.
What is the priority nursing intervention for a client with a history of asthma experiencing wheezing?
- A. Administer oxygen
- B. Apply a bronchodilator
- C. Apply a cold compress
- D. Encourage deep breathing
Correct Answer: A
Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
- A. Administer nitroglycerin
- B. Monitor cardiac rhythm
- C. Assess the ECG
- D. Assist with positioning
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
A 20-year-old construction worker has suffered heat stroke and has been brought into the emergency department. He has delirium as a result of fluid and electrolyte imbalance. The nurse will assess his:
- A. Affect and mood.
- B. Memory and affect.
- C. Thought processes and memory.
- D. Level of consciousness and cognitive abilities.
Correct Answer: D
Rationale: The correct answer is D: Level of consciousness and cognitive abilities. In this scenario, the individual is experiencing delirium due to fluid and electrolyte imbalance, which can affect his level of consciousness and cognitive abilities. Assessing these aspects is crucial in determining the severity of the condition and guiding appropriate interventions. Option A (Affect and mood) is incorrect as the primary concern is the individual's cognitive functioning. Option B (Memory and affect) is incorrect as it does not cover the assessment of consciousness. Option C (Thought processes and memory) is incorrect as it does not specifically address the evaluation of the individual's level of consciousness.