Which of the following would indicate that Mrs. Filbert understands what you have taught her about her condition?
- A. She delays asking for medication so that she will not become addicted
- B. She asks for medication upon the first indication of an attack
- C. She permits the nurse to perform all of her morning care
- D. She asks her family to assist her at mealtime
Correct Answer: B
Rationale: Promptly seeking medication at the onset of symptoms reflects understanding of how to manage acute attacks effectively.
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A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings.
A: Encouraging fluid intake is important but not the first priority.
C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress.
D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?
- A. Instruct the client to eliminate all vitamin K from the diet.
- B. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
- C. Refer the client to a chronic illness support group.
- D. Teach the client to use a soft-bristled toothbrush.
Correct Answer: B
Rationale: The correct answer is B: Prepare preoperative teaching for an inferior vena cava (IVC) filter. In the context of a client with an alteration in the gene CYP2C19 and recurrent pulmonary embolism, the use of an IVC filter helps prevent blood clots from traveling to the lungs. This intervention is crucial in managing the risk of further pulmonary embolism. Teaching the client about the purpose, care, and potential complications of the IVC filter is essential for their understanding and cooperation in the treatment plan.
Incorrect Choices:
A: Instruct the client to eliminate all vitamin K from the diet. This choice is not relevant to the management of recurrent pulmonary embolism associated with a genetic alteration.
C: Refer the client to a chronic illness support group. While support is important, it is not the immediate priority in this case of managing a recurrent PE.
D: Teach the client to use a soft-bristled toothbrush. This recommendation is not directly
Which patient is at greatest risk for pancreatic cancer?
- A. An elderly black male with a history of smoking and alcohol use.
- B. A young,white obese female with no known health issues.
- C. A young black male with juvenile onset diabetes.
- D. An elderly white female with a history of pancreatitis.
Correct Answer: A
Rationale: Smoking and alcohol use are major risk factors for pancreatic cancer, making the elderly black male with these habits at highest risk.
Place the steps for removal of a foreign body from the ear canal in the correct order.
- A. Refer for treatment of external otitis.
- B. Inspect the tympanic membrane for trauma.
- C. Obtain history for type of object.
- D. Choose appropriate fluid for irrigation or instillation.
Correct Answer: C
Rationale: Obtaining a history helps determine the safest method for removing the foreign body and prevents further injury.