Nokea
Which of the following signs and symptoms would indicate that the client is experiencing oxygen toxicity? Select all that apply.
- A. Nonproductive cough
- B. Nausea
- C. Restlessness
- D. Headache
- E. Substernal chest pain
- F. Nasal stuffiness
Correct Answer: A, D, E
Rationale: Oxygen toxicity from prolonged high-concentration oxygen can cause a nonproductive cough, headache, and substernal chest pain.
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When the physician prescribes the first-generation antihistamine for the client's symptomatic relief, the nurse appropriately advises the client that first-generation antihistamines are associated with which side effect?
- A. Weight loss
- B. Constipation
- C. Drowsiness
- D. Depression
Correct Answer: C
Rationale: First-generation antihistamines cross the blood-brain barrier, often causing drowsiness as a common side effect.
The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?
- A. Myocardial infarction.
- B. Pneumonia.
- C. Pulmonary embolus.
- D. Pneumothorax.
Correct Answer: C
Rationale: Sudden chest pain and impending doom in a DVT patient suggest pulmonary embolus (C), where a clot dislodges to the lungs, causing acute respiratory distress. Myocardial infarction (A) presents with cardiac symptoms. Pneumonia (B) has gradual onset. Pneumothorax (D) causes unilateral symptoms.
Which clinical manifestation indicates to the nurse the child has cystic fibrosis?
- A. Wheezing with a productive cough.
- B. Excessive salty sweat secretions.
- C. Multiple vitamin deficiencies.
- D. Clubbing of all fingers.
Correct Answer: B
Rationale: Excessive salty sweat (B) is a hallmark of cystic fibrosis due to defective chloride transport, detectable via sweat chloride testing. Wheezing/cough (A) is non-specific. Vitamin deficiencies (C) and clubbing (D) occur later but are not diagnostic.
Which is the best response from the nurse?
- A. Tell me more about how you are feeling.
- B. There are lots of things you can still do.
- C. You are just having a bad day today.
- D. What makes you say that?
Correct Answer: A
Rationale: Encouraging the client to express feelings fosters therapeutic communication and helps address emotional concerns related to COPD.
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?
- A. Gather the needed supplies for the procedure.
- B. Obtain a signed informed consent form.
- C. Assist the client into a side-lying position.
- D. Discuss the procedure with the client.
Correct Answer: B
Rationale: Informed consent (B) is required before invasive procedures, a priority. Gathering supplies (A), positioning (C), and discussion (D) follow.