After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
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Solution
Raise the side rails
Option D: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety.
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.
The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?
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Solution
The patient is under local anesthesia during the procedure
Option A: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.
Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?
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Solution
Chronic obstructive bronchitis
Option C: Because of this extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis.
Option A: Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen.
Options B and D: Clients with asthma and emphysema tend not to have chronic cough or peripheral edema.
Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?
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Solution
Bronchodilators
Option B: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow.
Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction.
Options C and D: Inhaled oral steroids may be given to reduce the inflammation but aren’t used for emergency relief.
Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?
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Solution
To determine the extent of lesions
Option C: If the lesions are large enough, the chest X-ray will show their presence in the lungs.
Option A: Sputum culture confirms the diagnosis.
Option B: There can be false-positive and false-negative skin test results.
Option D: A chest X-ray can’t determine if this is a primary or secondary infection.
Nurse Oliver is working in a outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?
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Solution
A 43-year-old homeless man with a history of alcoholism
Option C: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB.
Options A, B, and D: A high school student, daycare worker, and businessman probably have a much low risk of contracting TB
A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?
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Solution
Pneumonia
Option C: Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia.
Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively.
Option B: Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI.
Option D: The client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions.
When performing oral care on a comatose client, Nurse Krina should:
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Solution
Place the client in a side-lying position, with the head of the bed lowered.
Option C: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions.
Option A: Lemon glycerin can be drying if used for extended periods.
Option B: Brushing the teeth with the client lying supine may lead to aspiration.
Option D: Hydrogen peroxide is caustic to tissues and should not be used.
Nurse Ron is taking a health history of an 84-year-old client. Which information will be most useful to the nurse for planning care?
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Solution
Current health promotion activities
Option B: Recognizing an individual’s positive health measures is very useful.
Option A: General health in the previous 10 years is important, however, the current activities of an 84-year-old client are most significant in planning care.
Option C: Family history of disease for a client in later years is of minor significance.
Option D: Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem.
Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:
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Solution
Stay with him but not intervene at this time.
Option D: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing.
Option B: If the client is unconscious, she should lay him down.
Option C: A nurse should never leave a choking client alone.