Question

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Place the oxygen tank away from curtains or drapes.

Rationale :

🧯Flammable materials such as curtains can easily ignite if placed near a compressed oxygen source.

🔥Oxygen supports combustion, so even a small spark near flammable objects may cause a fire.

🪑Keeping the oxygen system away from drapes or fabrics minimizes risk of accidental ignition.

🚪Proper placement of oxygen tanks is a key aspect of home safety education in clients with COPD.

📌Core Message

In clients with COPD using oxygen, maintaining oxygen tank safety involves avoiding flammable surroundings to prevent combustion hazards.

Answer 2

Correct Answers

Blank 1 Correct Option: spontaneous abortion
Blank 2 Correct Option: cervical dilation

Rationale :

👶Spontaneous abortion refers to a pregnancy loss occurring before 20 weeks of gestation.

🧪Cervical dilation in the presence of bleeding strongly indicates an inevitable miscarriage.

📉The client’s HCG level is still elevated, but that does not rule out a spontaneous abortion.

🔬A history of infections may contribute, but current cervical changes are the most significant sign.

📌Core Message

In early pregnancy, spontaneous abortion is suspected when cervical dilation occurs with vaginal bleeding.

Answer 3

Correct Answers

Exudate on pharynx [ Acute Streptococcal Pharyngitis ]
Fever [ Epiglottitis ; Respiratory Syncytial Virus ; Acute Streptococcal Pharyngitis ]
Tachypnea [ Respiratory Syncytial Virus ]
Hypoxia [ Respiratory Syncytial Virus ]
Drooling [ Epiglottitis ]
Wheezing upon auscultation [ Respiratory Syncytial Virus ]

Rationale :

👅Exudates are classic for streptococcal pharyngitis, often presenting with sore throat and white patches.

🌡️Fever is a nonspecific symptom but commonly appears in all three infections due to inflammation.

💨Tachypnea and wheezing suggest lower respiratory tract involvement, typical in RSV.

💧Drooling and inability to swallow are hallmark signs of epiglottitis, a true airway emergency.

📌Core Message

Accurate classification of pediatric respiratory symptoms aids in differentiating RSV, strep throat, and epiglottitis to guide urgent care

Answer 4

Correct Answers

Blank 1 Correct Option: a change in mood
Blank 2 Correct Option: decreased night vision

Rationale :

🧠Isotretinoin can cause serious neuropsychiatric side effects, including mood changes and suicidal ideation.

👁️Decreased night vision is a known adverse effect due to vitamin A derivative toxicity.

💊The medication is potent and should be used under strict monitoring, especially in adolescents.

📞Any report of mental status changes or vision problems requires immediate provider notification.

📌Core Message

During isotretinoin therapy, adolescents must report mood changes or vision loss due to risk of psychiatric and ocular toxicity.

Answer 5

Correct Answers

Blank 1 Correct Option: opioid intoxication
Blank 2 Correct Option: pupil characteristics

Rationale :

🌀Opioid intoxication presents with depressed respiratory rate, altered mental status, and miosis (pinpoint pupils).

👁️Pupil constriction is a specific sign of opioid use, especially when seen with CNS depression.

💤The client was found unresponsive and required naloxone, indicating opioid overdose.

💉Presence of a needle and rapid response to naloxone supports the diagnosis of opioid intoxication.

📌Core Message

Opioid intoxication is identified by miosis and CNS depression, requiring prompt naloxone reversal.

Answer 6

Correct Answers:

Social worker

Rationale :

💸Social workers assist with resource access, including financial help and medication affordability.

📞They help connect clients to assistance programs like Medicaid, prescription discount plans, or nonprofit aid.

🏥This aligns with the nursing goal of promoting treatment adherence through interprofessional collaboration.

🤝Involving the social worker early supports the client’s long-term management and health outcomes.

📌Core Message

For clients unable to afford medications, the social worker helps access financial assistance and promotes medication adherence.

Answer 7

Correct Answers:

Speak in a neutral tone when addressing the client.

Rationale :

🗣️Clients with paranoid personality disorder are often suspicious and may misinterpret tone or expression.

🤐Using a neutral, consistent tone promotes trust and decreases potential for misinterpretation.

💬Clear communication helps the client feel respected and less threatened.

📘Therapeutic communication is essential for managing psychotic features without triggering defensive behavior.

📌Core Message

When caring for clients with paranoid personality disorder, use a neutral tone to support trust and therapeutic interaction.

Answer 8

Correct Answers

Blank 1 Correct Option: antibiotic prescription
Blank 2 Correct Option: WBC count
Blank 3 Correct Option: temperature

Rationale :

🧬A rising WBC count and elevated temperature suggest postoperative infection following colon resection.

🌡️Fever on Day 3 with increased leukocytosis indicates the body is mounting an immune response.

💉A prescription for antibiotics is indicated to prevent worsening infection or sepsis.

🩺Monitoring for complications such as anastomotic leak is critical in the post-surgical period.

📌Core Message

Rising WBC count and temperature post-surgery warrant antibiotic therapy to address potential infection.

Answer 9

Correct Answers:

"Plan to urinate every 3 hours while you are awake."

Rationale :

🕒Scheduled voiding every 2–3 hours helps retrain the bladder’s reflexes and reduce incontinence episodes.

🚽Urge incontinence involves sudden bladder contractions, so timing voids prevents accidents.

⏱️This approach gradually increases the bladder’s capacity and control.

💧Clients should not severely restrict fluids, as this can cause dehydration and irritation.

📌Core Message

To manage urge urinary incontinence, encourage scheduled voiding every few hours to build bladder control.

Answer 10

Correct Answers

Blank 1 Correct Option: pneumonia
Blank 2 Correct Option: shallow breathing
Blank 3 Correct Option: lack of incentive spirometer use

Rationale :

💤Shallow breathing limits lung expansion, increasing risk for atelectasis and pneumonia.

💁‍♂️Post-op preschoolers may avoid deep breathing due to pain, especially without incentive spirometer use.

⚠️This leads to hypoventilation, secretion buildup, and lung infection risk.

📉While bowel sounds and tenderness are expected, respiratory compromise is more urgent in pneumonia risk.

📌Core Message

Post-op shallow breathing and no incentive spirometry put preschoolers at high risk for pneumonia.

1 :
A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client at the clinic.

Correct Answers

3 :
A nurse is caring for an 18-month-old toddler in the emergency department.

Correct Answers

4 :
A nurse is caring for an adolescent in the outpatient dermatologist' office.

Correct Answers

5 :
A nurse is caring for a client in the emergency department.

Correct Answers

6 :
A nurse is doing discharge planning for a client who reports being unable to afford their medication. For which of the following interprofessional team members should the nurse schedule a referral?

7 :
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is caring for a client on the medical-surgical unit.

Correct Answers

9 :
A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

10 :
A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Correct Answers

Assessment Findings	Epiglottitis	Respiratory Syncytial Virus	Acute Streptococcal Pharyngitis
Exudate on pharynx
Fever
Tachypnea
Hypoxia
Drooling
Wheezing upon auscultation

1 : A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

2 : A nurse is caring for a client at the clinic.

Correct Answers

3 : A nurse is caring for an 18-month-old toddler in the emergency department.

Correct Answers

4 : A nurse is caring for an adolescent in the outpatient dermatologist' office.

Correct Answers

5 : A nurse is caring for a client in the emergency department.

Correct Answers

6 : A nurse is doing discharge planning for a client who reports being unable to afford their medication. For which of the following interprofessional team members should the nurse schedule a referral?

7 : A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

8 : A nurse is caring for a client on the medical-surgical unit.

Correct Answers

9 : A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

10 : A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Correct Answers

1 :
A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client at the clinic.

3 :
A nurse is caring for an 18-month-old toddler in the emergency department.

4 :
A nurse is caring for an adolescent in the outpatient dermatologist' office.

5 :
A nurse is caring for a client in the emergency department.

6 :
A nurse is doing discharge planning for a client who reports being unable to afford their medication. For which of the following interprofessional team members should the nurse schedule a referral?

7 :
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is caring for a client on the medical-surgical unit.

9 :
A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

10 :
A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.