Nokea
Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?
- A. Visual stuffiness
- B. Dry cough
- C. High fever
- D. Scratchy throat
Correct Answer: C
Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.
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A patient is ordered at 1400 to take Theophylline. You're assessing the patient's morning lab results and note that the Theophylline level drawn this morning reads: $15 \mathrm{mcg} / \mathrm{mL}$. You're next nursing action is to?
- A. Administer the dose at 1400 as ordered
- B. Notify the physician for further orders
- C. Hold the 1400 dose
- D. Collect another blood sample to confirm the level
Correct Answer: A
Rationale: A Theophylline level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the dose should be administered as ordered . No further action is needed.
The nurse knows to discontinue the client's sponge bath if the client develops which symptom?
- A. Nausea
- B. Chills
- C. Flushing
- D. Confusion
Correct Answer: B
Rationale: Chills during a sponge bath indicate the client is becoming too cold, which can worsen discomfort and should prompt discontinuation.
The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with cancer of the lung who has chest tubes.
- B. The client diagnosed with laryngeal spasms who has stridor.
- C. The client diagnosed with laryngeal cancer who has multiple fistulas.
- D. The client who is two (2) hours post-partial laryngectomy.
Correct Answer: A
Rationale: Chest tubes for lung cancer (A) are stable for a new graduate. Stridor (B), fistulas (C), and recent laryngectomy (D) require experienced care due to airway and complication risks.
Other than obtaining a vaccination against influenza, which nursing advice is most helpful to high-risk clients who want to avoid getting influenza?
- A. Consume adequate vitamin C.
- B. Avoid crowded places.
- C. Dress warmly in cold weather.
- D. Reduce daily stress and anxiety.
Correct Answer: B
Rationale: Avoiding crowded places reduces exposure to influenza, a highly contagious respiratory virus.
Which assessment finding indicates that the client has most likely developed pleurisy as a result of the pneumonia?
- A. Productive cough
- B. Pain when breathing
- C. Cyanotic nail beds
- D. Rapid heart rate
Correct Answer: B
Rationale: Pleurisy causes sharp chest pain during breathing due to inflammation of the pleural membranes.