Question

A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

Answer 1

Correct Answers:

Inform the client to seek medical attention following administration of the injection.

Rationale :

💎 Epinephrine provides temporary relief, but anaphylaxis can rebound once the drug wears off.

💎 Prompt medical evaluation is essential to monitor airway, breathing, and circulation post-injection.

💎 Further treatment such as antihistamines, steroids, or oxygen may be required in a clinical setting.

💎 Clients can deteriorate quickly, even after initial symptom relief.

💎 Epinephrine auto-injectors have a limited dose, and repeat administration may be necessary.

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Answer 2

Correct Answers:

Place the client in high-Fowler's position.

Rationale :

🟢 High-Fowler’s optimizes chest expansion, improving oxygenation during dyspnea.

🟢 Improves diaphragmatic descent, which is vital in respiratory distress.

🟢 Reduces venous return, potentially easing right heart strain in PE.

🟢 Immediate positioning is a priority to promote perfusion and comfort.

🟢 Positioning is a non-invasive, immediate intervention, prior to medications or diagnostics.

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Answer 3

Correct Answers:

Respiratory acidosis

Rationale :

🔵 Low pH (7.30) indicates acidosis.

🔵 Elevated PaCO₂ (50 mm Hg) confirms a respiratory origin.

🔵 Normal HCO₃ (26 mEq/L) rules out metabolic compensation.

🔵 Common in pneumonia, where CO₂ retention occurs.

🔵 Requires ventilation support to correct gas exchange imbalance.

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Answer 4

Correct Answers:

Brain natriuretic peptide 275 pg/mL

Rationale :

🟡 BNP is a cardiac biomarker, secreted by ventricles under stress.

🟡 Levels >100 pg/mL suggest heart failure, especially with symptoms like dyspnea.

🟡 Indicates volume overload, often due to decreased cardiac output.

🟡 Used to distinguish cardiac vs. respiratory causes of dyspnea.

🟡 Guides diuretic therapy decisions in acute HF management.

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Answer 5

Correct Answers:

Allow frequent rest periods.

Rationale :

🔶 Fatigue is common in heart failure due to reduced oxygenation and perfusion.

🔶 Rest reduces cardiac workload, allowing more efficient circulation.

🔶 Activity should be spaced to prevent decompensation.

🔶 Improves endurance while respecting physiological limits.

🔶 Rest periods are a core non-pharmacologic management component.

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Answer 6

Correct Answers:

Allow space for one finger to be placed under the tube ties.

Rationale :

🟣 Ensures the tube is secure but not too tight, preventing pressure injury.

🟣 Maintains airway patency while avoiding strangulation or skin breakdown.

🟣 Promotes skin integrity and circulation around the neck.

🟣 Prevents accidental decannulation during patient movement.

🟣 Reflects standard best practice in tracheostomy tie placement.

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Answer 7

Correct Answers:

1000

Rationale :

1 pound of fat = 3,500 kcal, so 2 lbs = 7,000 kcal.

✏️ Divide

👉 7,000 kcal by 7 days

= 1,000 kcal/day deficit.

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Answer 8

Correct Answers:

Do not eat or drink anything except water for 12 hr before the procedure.

Rationale :

➡️ The client should fast for 12 hours before the procedure to ensure the bowel is empty for better visualization.

➡️ A clear liquid diet is followed 12–24 hours before the procedure, not 1 to 3 days.

➡️ Enemas are usually given the night before or on the day of the colonoscopy, not two days prior.

➡️ Polyps are generally removed during the procedure, eliminating the need for a separate procedure.

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Answer 9

Correct Answers:

Sit in a straight-backed chair.

Rationale :

🔴 Sitting in a straight-backed chair ensures proper alignment and prevents excessive flexion or rotation, reducing the risk of dislocating the hip prosthesis.

🔴 This position helps to maintain the integrity of the hip joint and avoids harmful movements that could jeopardize the recovery process.

🔴 Abducting, flexing, and extending the hip as prescribed by physical therapy are important for the healing process.

🔴 Avoid actions like crossing legs or bending the hip beyond 90 degrees, as these could also cause complications.

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Answer 10

Correct Answers:

Blood pressure change from 118/78 mm Hg to 86/50 mm Hg

Rationale :

🟡 A drop in blood pressure from 118/78 mm Hg to 86/50 mm Hg is a critical finding and suggests hypotension, which could result from shock, blood loss, or dehydration.

🟡 Hypotension impairs tissue perfusion and oxygenation, leading to organ failure if not treated urgently.

🟡 The nurse should assess the client for signs of shock, such as tachycardia, pallor, and confusion, and promptly intervene.

🟡 Restoring blood pressure is crucial to maintain oxygen supply to vital organs.

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QLexNursing

1 :
A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

2 :
A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

3 :
A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

4 :
A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure?

5 :
A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

6 :
A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?

8 :
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

9 :
A nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?

QLexNursing

1 : A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

2 : A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

3 : A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

4 : A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure?

5 : A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

6 : A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?

8 : A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

9 : A nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

10 : A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?

1 :
A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

2 :
A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

3 :
A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

4 :
A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure?

5 :
A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

6 :
A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?

8 :
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

9 :
A nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?