NUR202Ch28&29Q

A nurse working in a geriatric clinic sees clients with “cold” symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?

• A. Teach the client about possible drowsiness.

• B. Instruct the client to drink plenty of water.

• C. Consult with the PHCP about the medication.

• D. Encourage the client to take the medication with food.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying “I have been drinking tons of water. How am I dehydrated?” What response by the nurse is best?

• A. “Breathing so quickly can be dehydrating.”

• B. “Everyone with pneumonia is dehydrated.”

• C. “This is really just to administer your antibiotics.”

• D. “Why do you think you are so dehydrated?”

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

• A. Community social worker for Meals on Wheels

• B. Occupational therapy for job retraining

• C. Physical therapy for homebound therapy services

• D. Visiting nurses for directly observed therapy

The emergency department nurse is participating in a bioterrorism drill in which several “clients” are suspected to have inhalation anthrax. Which “clients” would the nurse see as the priorities? (Select all that apply.)

• A. Widened mediastinum on chest x-ray

• B. Stridor

• C. Oxygen saturation of 91%

• D. Diaphoresis

• E. Oral temperature of 99.9° F (37.7° C)

Which finding is the most common indicator for pneumonia in an older patient?

• A. Fever

• B. Cough

• C. Confusion

• D. Increased white blood cell count

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client’s oxygen saturation has not significantly improved. What response by the nurse is best?

• A. “Breathing so rapidly interferes with oxygenation.”

• B. “Maybe the client has respiratory distress syndrome.”

• C. “The blood clot interferes with perfusion in the lungs.”

• D. “The client needs immediate intubation and mechanical ventilation.”

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

• A. Adherence to proper hand hygiene

• B. Administering antiulcer medication

• C. Turning and positioning the client at least every 2 hours

• D. Providing oral care per protocol

• E. Suctioning the client on a regular schedule

Which diagnosis would the nurse suspect for a patient who presents with pain in the throat, difficulty swallowing, swelling the throat, and difficulty in opening the mouth?

• A. Tonsilitis

• B. Pharyngitis

• C. Peritonsillar abscess

• D. Retropharyngeal abscess

The charge nurse on a medical unit is preparing to admit several “clients” who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

• Admit the “clients” on Contact Precautions.

• Inquire as to recent travel outside the United States.

• Do not allow pregnant caregivers to care for these “clients.”

• Place the “clients” on enhanced Droplet Precautions.

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client’s oxygen saturation has not significantly improved. What response by the nurse is best?

• “Breathing so rapidly interferes with oxygenation.”

• “Maybe the client has respiratory distress syndrome.”

• “The blood clot interferes with perfusion in the lungs.”

• “The client needs immediate intubation and mechanical ventilation.”