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Which question is essential for the nurse to ask before administering the influenza vaccine?
- A. Have you had influenza in the last year?
- B. Did you receive pneumonia vaccine last year?
- C. Are you allergic to eggs or egg products?
- D. Do you have a history of respiratory disease?
Correct Answer: C
Rationale: Influenza vaccines are often produced using eggs, so an egg allergy must be assessed to prevent allergic reactions.
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Which observation best indicates that a client with a pneumothorax is developing a tension pneumothorax?
- A. The trachea is deviated.
- B. The client is coughing.
- C. The chest is asymmetrical.
- D. The client reports sharp pain.
Correct Answer: A
Rationale: Tracheal deviation is a hallmark sign of tension pneumothorax, indicating mediastinal shift due to increased intrathoracic pressure.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.
Which explanation to the client by the nurse regarding the use of antibiotics is best?
- A. Antibiotics are ineffective in treating viral infections.
- B. Antibiotics are ineffective after cold symptoms develop.
- C. Antibiotics only prevent the spread of colds to others.
- D. Antibiotics are used only for immunosuppressed individuals.
Correct Answer: A
Rationale: Head colds are typically caused by viruses, and antibiotics are effective against bacterial infections, not viral ones.
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply.
- A. Assess the client's level of consciousness.
- B. Monitor urine output every shift.
- C. Turn the client every two (2) hours.
- D. Maintain intravenous fluids as ordered.
- E. Place the client in the Fowler's position.
Correct Answer: A,C,D,E
Rationale: LOC assessment (A), turning (C), IV fluids (D), and Fowler’s position (E) support ARDS care. Urine output (B) should be monitored hourly, not per shift.
The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?
- A. The client worked with asbestos for a short time many years ago.
- B. The client has no family history for this type of lung cancer.
- C. The client has numerous tattoos covering both upper and lower arms.
- D. The client has smoked two (2) packs of cigarettes a day for 20 years.
Correct Answer: D
Rationale: Smoking (D) (40 pack-years) is the primary risk factor for small cell lung cancer. Asbestos (A) is a risk but less significant, family history (B) is irrelevant, and tattoos (C) are unrelated.