Which isolation procedure should be instituted for the clien...

Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?

A. Airborne isolation.
B. Droplet isolation.
C. Reverse isolation.
D. Strict isolation.

Correct Answer: A

Rationale: SARS is transmitted via respiratory droplets and possibly aerosols, requiring airborne isolation (A) with a negative pressure room and N95 masks. Droplet isolation (B) is insufficient for potential aerosol transmission. Reverse isolation (C) protects immunocompromised patients, not applicable here. Strict isolation (D) is not a standard term for SARS precautions.

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You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately?

A. I'm seeing yellow halos around the light.'
B. My mouth tastes like metal.'
C. My head hurts.'
D. I have this constant ringing in my ears.'

Correct Answer: D

Rationale: Ringing in the ears indicates potential ototoxicity, a serious vancomycin side effect requiring immediate cessation and physician notification. Other symptoms (A, B, C) are less specific and not immediately alarming.

Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?

A. Visual stuffiness
B. Dry cough
C. High fever
D. Scratchy throat

Correct Answer: C

Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.

The nurse is planning the activities for the client diagnosed with asbestosis. Which activity should the nurse schedule at 0900 if breakfast is served at 0800?

A. Assist with the client's bath and linen change.
B. Administer an inhalation bronchodilator treatment.
C. Provide the client with a one (1)-hour rest period.
D. Have respiratory therapy perform chest physiotherapy.

Correct Answer: B

Rationale: Bronchodilator treatment (B) at 0900 optimizes lung function early in the day for asbestosis patients, who have restrictive lung disease. Bathing (A) is less urgent. A rest period (C) may be needed later, not immediately post-breakfast. Chest physiotherapy (D) is typically scheduled later to avoid postprandial discomfort.

Select all the correct options that represent the pathophysiology of an asthma attack.

A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation.
B. The mucosa lining experiences severe inflammation.
C. The goblet cells within the mucosa lining produce excessive amounts of mucous.
D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.

Correct Answer: B,C

Rationale: Asthma involves inflammation of the airway mucosa and excessive mucus production by goblet cells. Smooth muscle constriction occurs in bronchioles, not alveoli, and hyperventilation typically leads to respiratory acidosis due to CO2 retention.

The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply.

A. Keep the head of the bed elevated.
B. Encourage deep breathing exercises.
C. Record pulse oximeter reading.
D. Assess level of consciousness.
E. Auscultate breath sounds.

Correct Answer: A,C

Rationale: UAPs can keep the head of the bed elevated (1) to improve lung expansion and record pulse oximetry (3), a non-invasive task. Encouraging deep breathing (2) requires teaching, a nursing role. Assessing consciousness (4) and auscultating breath sounds (5) are assessment tasks reserved for nurses.