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A client with a productive cough has obtained a sputum
specimen for culture as instructed. What is the best initial
nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - ANSWER-B.
Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest
with cardiopulmonary resuscitation (CPR) in progress. The
client is intubated and is receiving 100% oxygen per self-
inflating (ambu) bag. The nurse determines that the client is
cyanotic, cold, and diaphoretic. Which assessment is most
important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
,B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - ANSWER-A. Breath sounds over
bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate
Antidiuretic Hormone (SIADH), a client develops pontine
myselinolysis. Which intervention should the nurse
implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - ANSWER-A. Reorient
client to his room
A male client with heart failure (HF) calls the clinic and
reports that he cannot put his shoes on because they are too
tight. Which additional information should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
,D. How many hours did he sleep last night? - ANSWER-B. Has
his weight changed in the last several days?
An older adult woman with a long history of chronic
obstructive pulmonary disease (COPD) is admitted with
progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which
intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - ANSWER-D. Assist her to
an upright position
A client with a history of asthma and bronchitis arrives at the
clinic with shortness of breath, productive cough with
thickened tenacious mucous, and the inability to walk up a
flight of stairs without experiencing breathlessness. Which
action is most important for the nurse to instruct the client
about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen
exposure
, C. Call the clinic if undesirable side effects of mediations
occur
D. Teach anxiety reduction methods for feelings of suffocation
- ANSWER-A. Increase the daily intake of oral fluids to liquefy
secretions
A cardiac catherterization of a client with heart disease
indicates the following blockages: 95% proximal left anterior
descending (LAD), 99% proximal circumflex, and ? % proximal
right coronary artery (RCA). The client later asks the nurse
"what does all this mean for me?" What information should
the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic
lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have
blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to
5% of blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk
of heart failure and fluid retention. - ANSWER-C. Three main
arteries have major blockages, with only 1 to 5% of blood
flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of
heparin 80 units/kg. The heparin is available in a 2 ml vial,
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