Extract:

Question 1 of 5

A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

A. Go to the emergency departmentB. Continue to use salmeterol and fluticasone as prescribedC. Administer an additional rescue dose of AlbuterolD. Call the physician

Correct Answer: C

Rationale: The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation.

Question 2 of 5

A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

A. CyanosisB. HypotensionC. BradycardiaD. Tachycardia

Correct Answer: D

Rationale: Tachycardia is an early compensatory mechanism to increase oxygen delivery in response to hypoxia.

Question 3 of 5

The nurse is caring for a client with uterine cancer who is being treated with brachytherapy. The UAP reports that the client ambulated to the restroom and is now reporting, 'something feels like it's coming out.' What is the nurse's priority action?

A. Assess for dislodgement and use forceps to retrieve the dislodged pellets and place in the lead container.B. Assess the patient's knowledge of the treatment plan and her willingness to participate.C. Assess the UP's knowledge and explain the rationale for strict bed rest.D. Notify the physician about the potential dislodgment of the radiation implant.

Correct Answer: A

Rationale: The priority action when a patient is receiving brachytherapy for uterine cancer is to assess for potential dislodgement of the radioactive implant. If the radiation source has been displaced, it must be handled carefully to prevent radiation exposure to the nurse, other patients, and staff. The nurse should use forceps to carefully retrieve the dislodged pellets and place them in a lead container to prevent contamination.

Question 4 of 5

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require immediate intervention?

A. The UAP stands by the patient's bed for 60 minutes talking with the patient.B. The UAP gives the patient a saline mouthwash to use for oral care.C. The UAP places the patient's bedding in the laundry container inside the clients room.D. The UAP flushes the toilet twice after emptying the patient's bedpan.

Correct Answer: A

Rationale: This action requires immediate intervention because of the potential radiation exposure to the UAP. A temporary radioactive cervical implant involves placing a radioactive source in or near the patient's cervix. Prolonged close contact increases the risk of radiation exposure.

Question 5 of 5

An older adult client with a history of heart failure is admitted to the hospital due to confusion, vision disturbance and anorexia for several days. The client has a pulse rate of 53 bpm, b/p of 116/68, respirations 16 and saturation of 97%. Which of the following medications does the nurse suspect could be causing the client's symptoms?

A. DigoxinB. DiltiazemC. PropanololD. Captopril

Correct Answer: A

Rationale: Confusion, vision disturbances, and anorexia are classic signs of digoxin toxicity, especially with bradycardia and a narrow therapeutic index.