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 :

🟢 Fire hazard prevention: Oxygen is highly combustible, and curtains/drapes are flammable materials that can easily catch fire if near an oxygen source.

🟢 Home safety: Oxygen tanks must be kept in a well-ventilated space, away from fabrics, heat sources, and direct sunlight.

🟢 Immediate accessibility: The tank wrench should always remain with the cylinder for quick shut-off in case of emergency, not locked away.

🟢 Storage rule: Tanks should be upright and secured, not under a bed where airflow is poor and damage risk is higher.

🟢 Monitoring use: Oxygen gauges should be checked daily, not weekly, to ensure adequate supply and prevent sudden depletion.

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Answer 2

Correct Answers

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

Rationale :

🟢 Spontaneous abortion: At 10 weeks gestation with bright red vaginal bleeding, abdominal cramping, and an open cervix, this presentation strongly indicates inevitable spontaneous abortion.

🟢 Cervical dilation: Confirms the pregnancy cannot continue, as the products of conception are being expelled.

🟢 hCG levels: Elevated but appropriate for gestation; not diagnostic for ectopic or molar pregnancy in this case.

🟢 Ectopic pregnancy: Would present with unilateral pain, low hCG, and no intrauterine pregnancy—not supported here.

🟢 Molar pregnancy: Typically associated with very high hCG, excessive nausea, and snowstorm ultrasound, absent here.

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Answer 3

Correct Answers

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

Rationale :

🔷 Exudate on pharynx → Acute Streptococcal Pharyngitis

Strep throat is caused by Group A beta-hemolytic streptococci, and a hallmark sign is tonsillar/pharyngeal exudate. This finding is not typical of RSV or epiglottitis, which involve airway swelling and obstruction rather than pus formation.

🔷 Fever → Epiglottitis, RSV, Strep

Fever is a nonspecific but common symptom across all three conditions:

Epiglottitis: Presents with sudden high fever due to acute bacterial infection .RSV: Often shows low-to-moderate fever with viral illness.

Strep throat: Usually includes moderate fever along with throat pain.

🔷 Tachypnea → Epiglottitis, RSV

Both epiglottitis and RSV impair the airway and lead to increased work of breathing.

Epiglottitis: The swollen epiglottis causes upper airway obstruction → rapid, shallow breathing.

RSV: Causes lower airway inflammation and mucus plugging, leading to rapid respiratory rate. Tachypnea is not expected in uncomplicated strep throat, since it mainly affects the throat, not the lungs.

🔷 Hypoxia → Epiglottitis, RSV

Epiglottitis: The narrowed airway prevents oxygen from entering, leading to oxygen desaturation.

RSV: Causes widespread bronchiolar obstruction from mucus and inflammation → impaired gas exchange. Hypoxia is not a feature of strep throat, which does not involve airway compromise.

🔷 Drooling → Epiglottitis

Drooling is a classic red flag for epiglottitis. The swollen epiglottis prevents swallowing, so the child cannot handle secretions. This is absent in RSV and strep throat, where swallowing is not obstructed.

🔷 Wheezing upon auscultation → RSV

Wheezing is caused by narrowed bronchioles and mucus plugging, which is characteristic of RSV bronchiolitis. Epiglottitis causes stridor (upper airway sound), not wheezing, and strep throat involves the pharynx only, so no wheezing is expected.

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Answer 4

Correct Answers

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

Rationale :

🔷 Isotretinoin use:

Isotretinoin is a vitamin A derivative used for severe, recalcitrant acne.

It has serious potential adverse effects that require close monitoring.

🔷 Change in mood:

Isotretinoin is strongly linked to depression, mood swings, and suicidal ideation.

Clients and families must report any mood change immediately for safety.

🔷 Decreased night vision:

Isotretinoin can cause ocular side effects, especially impaired dark adaptation/night vision, which may be sudden and irreversible.

This poses safety concerns (eg. driving at night) and must be reported right away.

🔷 Other listed options:

Dry mouth, dry eyes, nausea, worsening of acne, sunburn are common but expected side effects; they should be managed but are not emergencies.

Engagement in sexual activity is a risk concern due to isotretinoin’s teratogenicity, but it is addressed with mandatory pregnancy prevention programs (iPLEDGE).

🔷 Teaching priority:

Clients on isotretinoin need education about mental health monitoring and vision changes as priority safety alerts.

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Answer 5

Correct Answers

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

Rationale :

🔷 Clinical picture: The client was found unresponsive, pulseless, with a needle in the antecubital space. Responded to naloxone, a reversal agent for opioids → strongly indicates opioid overdose.

🔷 Respiratory depression: RR 10/min (low) with drowsiness and inability to stay awake → hallmark of opioid intoxication.

🔷 Pupil findings: Miotic (pinpoint pupils) are the classic opioid intoxication sign. Alcohol intoxication would not typically cause pinpoint pupils.

🔷 Amount of alcohol consumed: One beer is insufficient to explain this level of CNS depression, ruling out alcohol intoxication.

🔷 Withdrawal vs intoxication: Withdrawal from opioids/alcohol usually causes tachycardia, hypertension, agitation, diaphoresis, tremors, not sedation and pinpoint pupils. This client has depression of CNS and respirations, consistent with intoxication.

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Answer 6

Correct Answers:

Social worker

Rationale :

🟢 Role clarity: A social worker helps clients access financial resources, community programs, and insurance assistance for medications.

🟢 Barrier resolution: They connect clients to discount programs, medication vouchers, or government aid.

🟢 Advocacy: Social workers advocate for clients facing financial hardship to ensure continuity of care.

🟢 Team approach: Nurses collaborate with social workers to address non-medical needs impacting health.

🟢 Other options: Psychologists handle mental health therapy, pharmacy techs dispense meds but do not address financial issues, and OTs focus on ADLs/rehab.

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Answer 7

Correct Answers:

Speak in a neutral tone when addressing the client.

Rationale :

🔵 Paranoid personality disorder: Clients often misinterpret others’ motives and may feel threatened or suspicious.

🔵 Neutral communication: A calm, neutral tone avoids triggering paranoia or defensive reactions.

🔵 Therapeutic alliance: Builds trust and reduces perceived hostility, encouraging cooperation.

🔵 Respect autonomy: Direct but respectful communication reinforces boundaries while honoring independence.

🔵 Other options: Mixing meds secretly breaches ethical standards, limiting socialization worsens isolation, and rotating staff increases distrust.

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Answer 8

Correct Answers:

Maintain the irrigation solution rate.

Rationale :

🔷 Expected finding: Pink-tinged urine is normal 4 hr after TURP (indicates mild bleeding).

🔷 No intervention needed: Only bright red urine or clots would warrant adjusting the flow.

🔷 Irrigation purpose: Prevents clot formation and obstruction.

🔷 Safety: Abrupt changes to the rate can cause bladder spasms or overdistention.

🔷 Standard care: Nurse continues monitoring urine output and color while maintaining flow.

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Answer 9

Correct Answers:

Check gastric residuals every 4 hr.
Change the feeding container and tubing every 24 hr.
Maintain the head of the client's bed at a 30° angle or higher.

Rationale :

🟢 Check gastric residuals q4h: Prevents overfeeding and aspiration.

🟢 Change feeding set q24h: Reduces infection risk from bacterial growth.

🟢 Maintain HOB ≥30°: Decreases aspiration risk by keeping gastric contents down.

🟢 Formula temp: Should be room temperature, not cold, to avoid cramps.

🟢 Tube placement check: Verified by x-ray at insertion only, not daily.

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Answer 10

Correct Answers:

Identify possible precipitating factors related to the infections.

Rationale :

🔵 First step: Use the nursing process — assess before acting.

🔵 Root cause analysis: Find out why infections increased (e.g., poor technique, catheter dwell time).

🔵 Policy revision or training: Should follow after causes are identified.

🔵 Team approach: Evidence supports identifying trends before making systemic changes.

🔵 Quality improvement: Data collection is always step one.

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QLexNursing

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 assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

10 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

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

QLexNursing

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 assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

10 : A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

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 assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

10 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?