Nokea
Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
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Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.
A client with jaundice has which skin color?
- A. Pale
- B. Ruddy
- C. Yellow
- D. Pink
Correct Answer: C
Rationale: Jaundice causes yellow skin due to bilirubin accumulation, unlike the other color descriptions.
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance
- B. When started, therapy must not be interrupted to prevent opportunistic infection
- C. Therapy should be interrupted for one day each month to prevent toxicity
- D. Therapy should be interrupted for one week every three months to prevent toxicity
Correct Answer: A
Rationale: HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge - even taking a dose late. Choice B is incorrect because, when the virus is kept in check with anti-retrovirals, the client's own immune system is able to keep opportunistic infections at bay. Choices C and D are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be prescribed.
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. You can eat anything you want, but no foods with sugar.'
- B. You need to lose weight, so your diet must be a restricted one.'
- C. You need a diet and exercise program.'
- D. You must eliminate all salt, fat, and sugar from your diet.'
Correct Answer: C
Rationale: A balanced diet and exercise program are essential for managing diabetes, promoting glycemic control and overall health without extreme restrictions.
When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. warm, dry skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth.