Nokea
Your patient with asthma is taking Theophylline. Which product below should the patient avoid consuming?
- A. Caffeine
- B. Dairy
- C. Wheat
- D. Shellfish
Correct Answer: A
Rationale: Caffeine can increase theophylline levels, leading to toxicity, as both are xanthine derivatives.
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Which clinical manifestation indicates to the nurse the child has cystic fibrosis?
- A. Wheezing with a productive cough.
- B. Excessive salty sweat secretions.
- C. Multiple vitamin deficiencies.
- D. Clubbing of all fingers.
Correct Answer: B
Rationale: Excessive salty sweat (B) is a hallmark of cystic fibrosis due to defective chloride transport, detectable via sweat chloride testing. Wheezing/cough (A) is non-specific. Vitamin deficiencies (C) and clubbing (D) occur later but are not diagnostic.
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS?
- A. Low arterial oxygen when administering high concentration of oxygen.
- B. The client has dyspnea and tachycardia and is feeling anxious.
- C. Bilateral breath sounds clear and pulse oximeter reading is 95%.
- D. The client has jugular vein distention and frothy sputum.
Correct Answer: A
Rationale: Refractory hypoxemia (A) despite high oxygen confirms ARDS. Dyspnea/tachycardia (B) are nonspecific, clear sounds/95% SpO2 (C) are normal, and JVD/sputum (D) suggest heart failure.
How should the nurse position the client while undergoing a thoracentesis?
- A. Lithotomy position
- B. Sitting
- C. Prone
- D. Supine
Correct Answer: B
Rationale: Sitting upright with arms supported allows access to the pleural space and minimizes complications during thoracentesis.
Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain?
- A. Medicate the client and have the client take deep breaths.
- B. Encourage the client to take shallow breaths to help with the pain.
- C. Explain deep breaths do not have to be taken at this time.
- D. Tell the client if he doesn't take deep breaths, he could die.
Correct Answer: A
Rationale: Pain medication followed by deep breathing (A) prevents atelectasis. Shallow breaths (B), delaying (C), and fear tactics (D) are inappropriate.
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.