Nokea
Which type of shock has the highest mortality rate?
- A. Neurogenic shock
- B. Anaphylactic shock
- C. Hypovolemic shock
- D. Septic shock
Correct Answer: D
Rationale: Septic shock has a high mortality rate due to systemic inflammation and multiorgan dysfunction.
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When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Initiating oxygen therapy
- B. Providing immediate rest for the client
- C. Positioning the client in high-Fowler's
- D. Administering a nebulized beta-adrenergic
Correct Answer: D
Rationale: The correct answer is D: Administering a nebulized beta-adrenergic. This is the highest priority because it directly addresses the acute asthma exacerbation by helping to open up the airways and improve breathing. Step 1: Assess the client's respiratory status Step 2: Administering the nebulized beta-adrenergic medication to relieve bronchospasm and improve airflow Step 3: Monitor the client's response to the medication and adjust care accordingly. Other choices are incorrect because A: Oxygen therapy may be needed but addressing the bronchospasm is the priority. B: Rest is important but not the priority in managing an acute asthma exacerbation. C: Positioning is helpful but not the priority over administering the medication to improve breathing.
A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen via face mask. Given the client's symptoms and ABG results showing respiratory alkalosis and hypoxemia, the priority is to improve oxygenation. Administering oxygen via face mask will help increase the oxygenation levels and alleviate the hypoxemia. Mechanical ventilation (A) is not indicated as the client is able to maintain their own ventilation. Administering a sedative (C) is not appropriate without addressing the underlying respiratory issue. Assessing for pulmonary embolism (D) may be important but not the immediate priority in this case.
Which adaptations for performing the examination would be appropriate for the patient (select all that apply)?
- A. Make sure that a family member is with him.
- B. Handle the skin with care because of potential fragility.
- C. Keep the patient warm and comfortable during the assessment.
- D. Allow the patient to watch TV to distract him from any painful assessments.
Correct Answer: C
Rationale: The correct answers are 'Handle the skin with care because of potential fragility,' 'Keep the patient warm and comfortable during the assessment,' and 'Place the patient in a position of comfort and avoid unnecessary changes in position.' These adaptations address age-related vulnerabilities and promote patient cooperation.
The most common cause of death in patients age 65 or older is:
- A. Chronic obstructive pulmonary disease
- B. Breast cancer
- C. Coronary artery disease
- D. Alzheimer’s disease
Correct Answer: C
Rationale: Coronary artery disease remains the leading cause of death in older adults due to its prevalence and associated complications such as heart attacks and heart failure.