Nokea
Which response by the nurse is most appropriate at this time?
- A. The pain will lessen in a few minutes.
- B. I will stay with you until the physician comes.
- C. Why would you even think something like that?
- D. Are your financial affairs in order?
Correct Answer: B
Rationale: Staying with the client provides emotional support and ensures prompt intervention during a suspected pulmonary embolism.
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If the client has normal cardiovascular and renal function, what is an appropriate goal for oral intake in the next 24-hour period?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 3,000 mL
Correct Answer: D
Rationale: For a client with fever and influenza, 3,000 mL of fluid intake helps prevent dehydration, assuming normal cardiovascular and renal function.
The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?
- A. Administer intravenous fluids of normal saline at 125 mL/hr.
- B. Provide supplemental oxygen per nasal cannula at 2 L/min.
- C. Continuous telemetry monitoring with strips every four (4) hours.
- D. Administer a loop diuretic intravenously every six (6) hours.
Correct Answer: A
Rationale: A mean pulmonary artery pressure of 35 mm Hg indicates pulmonary hypertension, common in end-stage COPD. IV fluids at 125 mL/hr (A) risk fluid overload and worsening right heart strain, so this order should be questioned. Oxygen (B), telemetry (C), and diuretics (D) are appropriate to manage hypoxia, monitor cardiac status, and reduce fluid overload.
The nurse provides directions to the client on the proper use of a peak flow meter. Arrange the steps for the nurse's instruction to the client on the proper use of a peak flow meter in the correct sequence.
- A. Slide the marker to zero.
- B. Take a deep breath.
- C. Put the mouthpiece of the flow meter into your mouth.
- D. Blow out as fast as you can.
- E. Empty all of the air from your lungs.
- F. Record the highest rating after the current sequence.
Correct Answer: A, B, C, D, E, F
Rationale: The correct sequence is: 1. Slide the marker to zero, 2. Take a deep breath, 3. Put the mouthpiece in your mouth, 4. Blow out as fast as you can, 5. Empty all of the air from your lungs, 6. Record the highest rating.
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications?
- A. I should take two (2) puffs when I begin to have an asthma attack.
- B. I must taper off the medications and not stop taking them abruptly.
- C. These drugs will be most effective if taken at bedtime.
- D. These drugs are not good at the time of an attack.
Correct Answer: D
Rationale: Mast cell stabilizers (D) prevent asthma by stabilizing mast cells, not treating acute attacks. Puffs during attack (A), tapering (B), and bedtime use (C) are incorrect.
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.