Nokea
A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?
- A. Fever
- B. Bradycardia
- C. Dry skin
- D. Decreased respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Fever. When the body is fighting an infection or inflammation, fever is a common manifestation due to the release of pyrogens that reset the body's temperature. Bradycardia (B) is a slow heart rate, not typically associated with infection. Dry skin (C) is more indicative of dehydration or a skin condition. Decreased respiratory rate (D) is not a common manifestation of infection. In this case, fever is the most expected manifestation due to the body's response to an infection.
You may also like to solve these questions
A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will receive a limited amount of pain medication when I press the button.
- B. I should have my family press the button for me when I am asleep.
- C. I can receive as much pain medication as I need by pressing the button.
- D. I should wait until my pain is severe before using the PCA pump.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the concept of patient-controlled analgesia (PCA) pump, where they will receive a limited amount of pain medication when they press the button. This indicates the client knows they have control over their pain relief.
Choice B is incorrect as having someone else press the button goes against the purpose of PCA, which is for the patient to self-administer medication. Choice C is incorrect because unlimited medication can lead to overdose. Choice D is incorrect as waiting for severe pain can lead to ineffective pain management.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse do next.
- A. Administer flumazenil to the client.
- B. Initiate gastric lavage with activated charcoal.
- C. Place the client in the Trendelenburg position.
- D. Obtain a stat CT scan of the brain.
Correct Answer: A
Rationale: The correct answer is A: Administer flumazenil to the client. Flumazenil is a specific benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, which includes respiratory depression. Administering flumazenil would help reverse the sedative effects of benzodiazepines and improve the client's respiratory status. Initiating gastric lavage with activated charcoal (B) is not the immediate priority after securing the airway and IV. Placing the client in the Trendelenburg position (C) is not recommended due to potential complications. Obtaining a stat CT scan of the brain (D) is not necessary at this point and does not address the immediate concerns of airway and sedation reversal.
A nurse is providing discharge teaching to a client following a total gastrectomy.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
A nurse is teaching dietary guidelines to a client who has celiac disease.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management.
Which type of insulin should the nurse anticipate administering?
- A. Glargine insulin.
- B. Regular insulin.
- C. NPH insulin.
- D. Insulin aspart.
Correct Answer: A
Rationale: The correct answer is A: Glargine insulin because it is a long-acting insulin with a duration of action of up to 24 hours, providing a basal level of insulin throughout the day. It is typically administered once daily at the same time each day to maintain stable blood glucose levels. Regular insulin (B) is short-acting and is usually given before meals. NPH insulin (C) is intermediate-acting and has a peak action of 4-12 hours. Insulin aspart (D) is a rapid-acting insulin used for mealtime coverage. In this scenario, the nurse should anticipate administering Glargine insulin for its long-acting, basal properties.