Unit 1(Respiratory)
I A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following assessments requires immediate follow-up?
A. Respiratory rate of 10 breaths/min
B. Oxygen saturation of 92%
C. Pursed-lip breathing during exertion
D. Barrel-shaped chest
Correct Answer: A. Respiratory rate of 10 breaths/min
Rationale: A low respiratory rate in a COPD patient receiving oxygen could indicate CO₂ retention due to hypoventilation. These patients rely on hypoxic drive, and excessive oxygen can suppress their respiratory effort.
A nurse is caring for a client with heart failure who is receiving furosemide. Which laboratory value is most important to monitor?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Correct Answer: C.
Furosemide is a loop diuretic that can cause hypokalemia, increasing the risk of arrhythmias.
A nurse is teaching a client with newly diagnosed hypothyroidism about levothyroxine. Which statement indicates understanding?
A. “I will take this medication at bedtime with food.”
B. “It may take a few weeks before I notice improvement.”
C. “If I feel better, I can stop taking the medication.”
D. “This medication will make me drowsy.”
Correct Answer: B.
Levothyroxine takes several weeks to reach full effect. It must be taken consistently and long term, ideally in the morning on an empty stomach.
A nurse is caring for a client who just had cataract surgery on the right eye. Which statement by the client indicates a need for further teaching?
A. “I will wear an eye shield at night while I sleep.”
B. “I will avoid lifting anything heavier than 10 pounds.”
C. “I will sleep on my right side to keep pressure off the other eye.”
D. “I will avoid bending at the waist.”
Correct Answer: C.
The client should avoid sleeping on the operative side (right side in this case) to reduce pressure on the healing eye.
A nurse is assessing a client with glomerulonephritis. Which finding is most concerning?
A) Decreased urine output
B) Periorbital edema
C) Hypertension
D) Hematuria
Correct Answer: A. Decreased urine output
Rationale: Decreased urine output may indicate worsening kidney function or the development of acute kidney injury, requiring immediate attention.
A newborn is 1 minute old with the following findings: heart rate 90 bpm, weak cry, some flexion of extremities, grimace when stimulated, and acrocyanosis. What is the infant’s APGAR score?
A. 4
B. 5
C. 6
D. 7
Correct Answer: B. 5
Rationale: HR <100 = 1, weak cry = 1, flexion = 1, grimace = 1, acrocyanosis = 1; total = 5.*
A patient is being discharged with a prescription for a corticosteroid inhaler. Which instruction is most important?
A. “Use this inhaler only when symptoms occur.”
B. “Shake the inhaler vigorously before use.”
C. “Use this inhaler before using a rescue inhaler.”
D. “Rinse your mouth after each use.”
Correct Answer: D. “Rinse your mouth after each use.”
Rationale: Rinsing the mouth after corticosteroid inhaler use helps prevent oral thrush (candidiasis), a common side effect.
A client arrives in the emergency department with chest pain, diaphoresis, and shortness of breath. Which is the nurse’s priority action?
A. Place the client in a supine position
B. Obtain a 12-lead ECG
C. Administer sublingual nitroglycerin
D. Assess family history of cardiac disease
Correct Answer: B.
An ECG should be done immediately in suspected myocardial infarction to guide urgent treatment.
A client is admitted in thyrotoxic crisis (thyroid storm). Which is the nurse’s priority action?
A. Place the client in Trendelenburg position
B. Administer acetaminophen for fever
C. Monitor for signs of hypoglycemia
D. Maintain a cool, quiet environment
Correct Answer: D.
Thyroid storm is a hypermetabolic state; minimizing stimuli and controlling temperature, HR, and BP are priorities.
A nurse is providing discharge instructions to a client with Meniere’s disease. Which of the following statements indicates understanding of the teaching?
A. “I should increase my salt intake to maintain fluid balance.”
B. “I will move my head quickly if I begin to feel dizzy.”
C. “I should avoid caffeine and alcohol.”
D. “I do not need to take any medications during symptom-free periods.”
Correct Answer: C.
Clients with Meniere’s disease are advised to avoid caffeine, alcohol, and high-sodium foods, which can worsen symptoms.
A nurse is caring for a client with nephrotic syndrome. Which dietary modification should the nurse recommend?
A) High-protein, low-sodium diet
B) Low-protein, high-sodium diet
C) High-protein, high-sodium diet
D) Low-protein, low-sodium diet
Correct Answer: A. High-protein, low-sodium diet
Rationale: Nephrotic syndrome leads to protein loss in urine. A high-protein diet helps compensate for this loss. A low-sodium diet helps manage edema.
A nurse is assessing a term newborn 2 hours after birth. Which finding requires immediate intervention?
A. Periodic breathing with brief pauses <15 seconds
B. Heart rate of 130 bpm
C. Nasal flaring and intercostal retractions
D. A soft, bow-shaped anterior fontanel
Correct Answer: C. Nasal flaring and intercostal retractions
Rationale: Signs of respiratory distress in a newborn warrant prompt evaluation and support of the airway and breathing.*
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 L/min via nasal cannula. Which of the following actions by the nurse is most appropriate?
A. Encourage the client to perform deep-breathing exercises every hour.
B. Increase the oxygen flow rate to 6 L/min if the client appears short of breath.
C. Notify the healthcare provider because the oxygen flow rate is too high.
D. Administer a bronchodilator before meals.
Correct Answer: C.
Clients with COPD are at risk for oxygen-induced hypoventilation. Oxygen is typically maintained at 1–2 L/min to avoid suppressing their respiratory drive.
A client with atrial fibrillation is receiving warfarin. Which statement indicates a need for further teaching?
A. “I’ll have my blood tested regularly.”
B. “I can take ibuprofen if I have a headache.”
C. “I’ll try to eat the same amount of leafy greens each week.”
D. “I will use a soft-bristled toothbrush.”
Correct Answer: B.
Ibuprofen increases the risk of bleeding and should be avoided with warfarin.
A client with hyperparathyroidism is at risk for which of the following complications?
A. Hypertension
B. Respiratory acidosis
C. Renal stones
D. Hypoglycemia
Correct Answer: C.
Hyperparathyroidism increases calcium levels, which can lead to the formation of renal stones (kidney stones).
A nurse is caring for a client with glaucoma. Which of the following findings would the nurse expect?
A. Sudden onset of eye pain and halos around lights
B. Gradual loss of peripheral vision
C. Complete loss of central vision
D. Eye redness and itching
Correct Answer: B.
Glaucoma typically presents with a gradual loss of peripheral vision. Acute angle-closure glaucoma may cause sudden symptoms, but chronic types progress silently.
A client with cirrhosis is experiencing ascites. Which of the following interventions should the nurse implement first?
A) Administering diuretics as prescribed
B) Restricting sodium intake
C) Measuring abdominal girth daily
D) Preparing the client for paracentesis
Correct Answer: C. Measuring abdominal girth daily
Rationale: Monitoring abdominal girth helps assess the progression of ascites and the effectiveness of interventions.
A mother plans to breastfeed. Which teaching point should the nurse include about newborn feeding cues?
A. “Wait until your baby is crying loudly before offering the breast.”
B. “Watch for rooting, hand-to-mouth movements, and sucking motions.”
C. “Feed every 6–8 hours to allow for longer sleep periods.”
D. “Offer a pacifier first to see if the baby is hungry.”
Correct Answer: B. “Watch for rooting, hand-to-mouth movements, and sucking motions.”
Rationale: Early hunger cues (rooting, hand-to-mouth) signal readiness to feed; waiting for crying may make feeding more difficult.*
The nurse is teaching a client with asthma how to use a metered-dose inhaler (MDI). Which of the following statements by the client indicates correct understanding?
A. “I should inhale quickly while pressing the canister.”
B. “I need to exhale immediately after inhaling the medication.”
C. “I should hold my breath for 10 seconds after inhaling.”
D. “I’ll clean the mouthpiece with water once a week.”
Correct Answer: C.
Holding the breath allows better absorption of the medication in the lungs.
The nurse is caring for a client with pericarditis. Which finding is most concerning?
A. Sharp chest pain relieved by leaning forward
B. Friction rub on auscultation
C. Jugular vein distention and muffled heart sounds
D. Low-grade fever and fatigue
Correct Answer: C.
These are signs of cardiac tamponade, a medical emergency caused by fluid compressing the heart.
A client with hypothyroidism is prescribed levothyroxine. The nurse should monitor for which of the following signs of overdose?
A. Bradycardia and weight gain
B. Diarrhea and palpitations
C. Hypotension and cold intolerance
D. Dry skin and coarse hair
Correct Answer: B.
Levothyroxine overdose can cause symptoms of hyperthyroidism, such as tachycardia, diarrhea, and palpitations.
A nurse is assessing a client with suspected stroke. Which finding is most consistent with a left-sided cerebrovascular accident (CVA)?
A. Impulsive behavior and poor judgment
B. Left-sided hemiparesis
C. Difficulty speaking and understanding language
D. Neglect of the left side of the body
Correct Answer: C.
A left-sided CVA often results in language deficits (aphasia) and right-sided weakness.
A nurse is caring for a client with acute pancreatitis. Which of the following interventions is most important?
A) Administering morphine sulfate for pain relief
B) Encouraging oral intake of fluids and foods
C) Providing a low-fat diet
D) Administering intravenous fluids as prescribed
Correct Answer: D. Administering intravenous fluids as prescribed
Rationale: Acute pancreatitis often leads to fluid shifts and dehydration. Administering intravenous fluids helps maintain circulatory volume and prevent complications.
A laboring client’s fetal monitor tracing shows a late deceleration with each contraction. What is the nurse’s priority action?
A. Turn the client to her left side
B. Decrease the oxytocin infusion rate
C. Apply oxygen via face mask at 8 L/min
D. Notify the healthcare provider
Correct Answer: A. Turn the client to her left side
Rationale: Changing position improves uteroplacental perfusion and often corrects late decelerations; then assess, oxygenate, and notify if persists.*
A nurse is caring for a postoperative client who suddenly develops shortness of breath, tachypnea, and chest pain. Which is the priority nursing action?
A. Elevate the head of the bed
B. Call the rapid response team
C. Obtain a stat chest X-ray
D. Check oxygen saturation and apply nasal cannula
Correct Answer: B.
These are signs of a possible pulmonary embolism; the rapid response team should be called immediately to stabilize the client.
A client presents with chest pain unrelieved by rest or nitroglycerin. Which laboratory test is most indicative of myocardial infarction?
A. Creatine kinase (CK)
B. Myoglobin
C. Troponin I
D. Lactate dehydrogenase (LDH)
Correct Answer: C.
Troponin I is the most specific and sensitive marker for myocardial injury, rising within hours of an MI.
A client with impetigo is prescribed topical mupirocin. Which statement by the client indicates the need for further teaching?
A. “I should apply the ointment to the affected areas twice daily.”
B. “I will wash my hands before and after applying the ointment.”
C. “I can stop the ointment when the rash is no longer visible.”
D. “I will keep the affected area clean and dry.”
Correct Answer: C.
Clients should complete the full course of treatment, even if the rash appears to be healed. Stopping prematurely may lead to a recurrence of the infection.
A client has been diagnosed with a transient ischemic attack (TIA). What is the primary purpose of this diagnosis?
A. To confirm the client had a stroke
B. To predict the likelihood of future strokes
C. To identify a brain tumor early
D. To assess for traumatic brain injury
Correct Answer: B.
TIAs are temporary episodes of neurological dysfunction that serve as a warning sign for a possible future stroke.
A nurse is teaching a client about a clear-liquid diet prior to a colonoscopy. Which selection by the client indicates understanding?
A. Tomato juice
B. Apple juice
C. Orange gelatin
D. Cream of chicken
Correct Answer: B. Apple juice
Rationale: Clear juices without pulp (like apple juice) are allowed. Tomato juice and orange gelatin are red/orange dyes that can mimic blood; cream soup is not clear.
A postpartum client is 2 hours after delivery of a 3,500-g infant. Fundus is boggy, and lochia is bright red and saturated one peripad in 10 minutes. What is the nurse’s first intervention?
A. Massage the fundus firmly
B. Increase the IV oxytocin infusion
C. Check for bladder distension
D. Notify the physician
Correct Answer: A. Massage the fundus firmly
Rationale: Uterine atony is the most common cause of early postpartum hemorrhage; fundal massage is the immediate corrective action.*
A client with tuberculosis (TB) is being discharged on rifampin. Which client statement indicates a need for further teaching?
A. “I will avoid alcohol while taking this medication.”
B. “I know my urine and tears might turn orange.”
C. “I will take the medication on an empty stomach.”
D. “I can stop taking the medication when I feel better.”
Correct Answer: D.
Clients must complete the full TB treatment course to prevent resistance and relapse. Stopping early is dangerous.
A nurse is teaching a client about lifestyle changes for hypertension. Which client statement indicates a need for further teaching?
A. “I will walk for 30 minutes five days a week.”
B. “I’ll cut back on salty foods like chips and canned soup.”
C. “I can stop taking my medication once my BP is normal.”
D. “I’ll check my blood pressure at home regularly.”
Correct Answer: C.
Hypertension is often lifelong, and medications should not be stopped without medical guidance—even if BP normalizes.
A client is diagnosed with scabies. What teaching should the nurse provide?
A. “Scabies can be treated with oral antibiotics.”
B. “Wash all clothing and linens in hot water.”
C. “Scabies spreads only through contaminated food.”
D. “You are no longer contagious once the itching stops.”
Correct Answer: B.
Scabies is caused by a mite and requires all fabrics to be washed in hot water to eliminate infestation.
A client experiences a generalized tonic-clonic seizure. What is the priority nursing action during the seizure?
A. Insert a padded tongue blade to prevent biting
B. Turn the client to the side and protect the head
C. Restrain the client’s arms and legs
D. Administer a benzodiazepine immediately
Correct Answer: B.
During a seizure, turn the client to the side to maintain the airway and prevent aspiration. Never restrain or put anything in the mouth.
A client with peptic ulcer disease reports coffee-ground emesis. The nurse’s priority action is to:
A. Encourage the client to rest and avoid movement
B. Document the finding and continue monitoring
C. Obtain vital signs and assess for orthostatic changes
D. Offer the client ice chips to soothe the throat
Correct Answer: C. Obtain vital signs and assess for orthostatic changes
Rationale: Coffee-ground emesis indicates digested blood. Assessing for hypotension or tachycardia identifies hypovolemia and guides prompt fluid resuscitation.
A postpartum Rh-negative mother delivered an Rh-positive infant. Which action should the nurse implement?
A. Administer Rho(D) immune globulin within 72 hours
B. Obtain a direct Coombs’ test on the mother’s blood
C. Encourage early cord clamping to prevent sensitization
D. Advise the mother that no further treatment is needed
Correct Answer: A. Administer Rho(D) immune globulin within 72 hours
Rationale: Rho(D) immune globulin given within 72 hours of an Rh-incompatible delivery prevents maternal antibody formation and future hemolytic disease of the newborn.
A client in the emergency department presents with wheezing, dyspnea, and a history of asthma. Which medication should the nurse anticipate administering first?
A. Fluticasone
B. Albuterol
C. Montelukast
D. Salmeterol
Correct Answer: B.
Albuterol is a short-acting beta-agonist (SABA) used as a rescue inhaler for acute asthma exacerbation.
A client is scheduled for a cardiac catheterization. Which finding should the nurse report to the provider before the procedure?
A. History of diabetes
B. Allergy to iodine
C. Pulse of 88 bpm
D. Blood pressure of 130/80 mmHg
Correct Answer: B.
An iodine allergy (or shellfish allergy) is critical to report as contrast dye used in catheterization may trigger a reaction.
A nurse is caring for a client with type 1 diabetes who is sweating, confused, and has a blood glucose of 52 mg/dL. What is the priority nursing action?
A. Administer long-acting insulin
B. Give 4 oz of orange juice
C. Recheck the blood glucose in 30 minutes
D. Notify the healthcare provider
Correct Answer: B.
The client is hypoglycemic. Administer a fast-acting carbohydrate like juice to raise blood glucose quickly.
A nurse is educating a client newly diagnosed with epilepsy. Which statement requires further teaching?
A. “I will avoid alcohol to reduce seizure risk.”
B. “I should take my medication even if I haven’t had a seizure in months.”
C. “I can drive 1 week after starting my medications.”
D. “I should wear a medical alert bracelet.”
Correct Answer: C.
Driving is restricted after a seizure diagnosis until the individual is seizure-free for a provider-specified period, often several months or longer.
A nurse is teaching a client about managing gastroesophageal reflux disease (GERD). Which statement by the client indicates correct understanding?
A. “I’ll lie down immediately after meals to rest.”
B. “I’ll avoid eating 2–3 hours before bedtime.”
C. “I can drink tomato juice to soothe my stomach.”
D. “I’ll wear tight clothing around my waist to support my abdomen.”
Correct Answer: B. “I’ll avoid eating 2–3 hours before bedtime.”
Rationale: Allowing time between eating and lying down reduces reflux risk. Tomato juice is acidic, and tight clothing increases intra-abdominal pressure.
A laboring client’s fetal monitor shows repetitive variable decelerations with moderate variability. The mother feels comfortable, membranes intact, and oxytocin off. What nursing intervention is most appropriate?
A. Prepare for operative delivery
B. Encourage maternal pushing
C. Change maternal position and provide IV bolus
D. Apply internal fetal scalp electrode
Correct Answer: C.
Variable decels often result from cord compression—repositioning the mother (e.g., lateral tilt) and ensuring adequate intravascular volume with a fluid bolus can relieve compression and improve FHR.
The nurse is caring for a client with cystic fibrosis (CF). Which intervention is most important in preventing respiratory complications?
A. Limiting fluid intake to reduce mucus
B. Providing a high-protein diet
C. Performing chest physiotherapy
D. Administering antibiotics as needed
Correct Answer: C.
Chest physiotherapy helps mobilize thick secretions and is crucial in CF care to prevent infections and maintain airway patency.
A client with heart failure is prescribed spironolactone. Which food should the nurse instruct the client to avoid?
A. Apples
B. Bananas
C. Rice
D. Chicken breast
Correct Answer: B.
Spironolactone is a potassium-sparing diuretic. Bananas are high in potassium and may increase the risk of hyperkalemia.
A client with type 2 diabetes is prescribed metformin. Which finding should the nurse report immediately?
A. Nausea and bloating
B. Blood glucose of 180 mg/dL
C. Muscle pain and fatigue
D. Creatinine level of 1.9 mg/dL
Correct Answer: D.
Metformin is contraindicated in renal impairment due to the risk of lactic acidosis. A high creatinine is a red flag.
A nurse is assessing a client with osteoarthritis (OA). Which finding is most consistent with this diagnosis?
A. Pain and stiffness that improve with rest
B. Joint inflammation and redness that occurs after activity
C. Symmetrical joint involvement, especially in the hands and wrists
D. Joint pain that is relieved by application of heat
Correct Answer: B.
Osteoarthritis (OA) typically presents with pain and stiffness that worsens with activity and improves with rest. Joint inflammation and redness may occur after excessive activity, especially in weight-bearing joints.
A nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) with biopsy. Which finding requires the nurse’s priority action?
A. Sore throat and mild hoarseness
B. Small amount of blood-tinged sputum
C. Absence of gag reflex 2 hours post-procedure
D. Complaints of bloating and abdominal gas
Correct Answer: C. Absence of gag reflex 2 hours post-procedure
Rationale: The gag reflex must return before allowing oral intake to prevent aspiration. Sore throat, minimal blood-tinged sputum, and gas are expected.
A 32-year-old woman reports severe dysmenorrhea and pelvic pain that worsens during her period. She’s diagnosed with endometriosis. Which intervention should the nurse discuss first?
A. Scheduled limited exercise during menses
B. Oral contraceptive pills taken continuously
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock
D. Laparoscopic ablation of endometrial implants
Correct Answer: C.
Rationale: First-line management of endometriosis pain is NSAIDs to reduce prostaglandin-mediated cramping. Continuous OCPs can follow if NSAIDs alone are insufficient; surgery is reserved for refractory or fertility-threatening cases. Gentle exercise may help but is adjunctive to pharmacologic therapy.
A nurse is assessing a client with emphysema. Which finding is most consistent with this condition?
A. Cyanotic lips and mucous membranes
B. Dullness on percussion
C. Pursed-lip breathing and prolonged expiration
D. Inspiratory wheezing
Correct Answer: C.
Pursed-lip breathing and prolonged expiration help prevent airway collapse during exhalation in emphysema.
A client with sickle cell disease presents with severe pain and fever. What is the nurse’s priority intervention?
A. Administer IV fluids
B. Apply cold compresses
C. Encourage ambulation
D. Teach relaxation techniques
Correct Answer: A.
IV fluids help reduce blood viscosity and prevent further sickling. Pain and fever suggest a vaso-occlusive crisis.
A nurse is caring for a client who received a kidney transplant 2 weeks ago and is on immunosuppressant therapy. Which symptom is most concerning?
A. Mild hand tremors
B. Temperature of 100.8°F (38.2°C)
C. Slight nausea in the morning
D. Increased appetite
Correct Answer: B.
Even a low-grade fever may indicate infection or rejection in immunosuppressed clients. It should be reported immediately.
A nurse is teaching a client about how to manage a sprained ankle. Which statement by the client indicates that further teaching is needed?
A. “I will elevate the ankle above the level of my heart to reduce swelling.”
B. “I will apply ice for 20 minutes every hour during the first 24 hours.”
C. “I will wrap the ankle tightly with an elastic bandage to prevent swelling.”
D. “I will rest the ankle for the first 2 days and then start exercising it.”
Correct Answer: C.
The ankle should be wrapped snugly but not tightly. Wrapping it too tightly can impair circulation and increase the risk of further injury.
A client prescribed furosemide for fluid overload asks why the nurse monitors their potassium. Which response by the nurse is best?
A. “Furosemide increases your potassium levels, which can cause cramps.”
B. “This medication can deplete potassium and lead to dangerous heart rhythms.”
C. “Potassium and fluid balance aren’t related, but it’s a routine check.”
D. “Your doctor likes to check all electrolytes whenever diuretics are used.”
Correct Answer: B.
Furosemide is a loop diuretic that can cause significant potassium loss in the urine, increasing the risk of arrhythmias—hence the need for close monitoring.
A 24-year-old woman is treated for bacterial vaginosis with metronidazole. Which of the following statements by the client indicates correct understanding?
A. “I can have a glass of wine with dinner tonight.”
B. “I should finish the entire course even if symptoms resolve.”
C. “I’ll use a condom to protect my partner during treatment.”
D. “I should avoid dairy products while on this medication.”
Correct Answer: B. “I should finish the entire course even if symptoms resolve.”
Rationale: Completing the full antibiotic course prevents recurrence. Alcohol must be avoided during and 48 hours after metronidazole; condoms are not necessary for BV treatment; no dairy restriction is needed.
A nurse is teaching a client about the use of an incentive spirometer. Which statement by the client indicates a need for further teaching?
A. “I should use it 10 times every hour while awake.”
B. “I should exhale into the device slowly and steadily.”
C. “It helps prevent lung complications after surgery.”
D. “I should try to keep the indicator at the target level.”
Correct Answer: B.
The client should inhale slowly and deeply—not exhale—into the incentive spirometer.
A client with pernicious anemia asks why they need vitamin B12 injections for life. What is the nurse’s best response?
A. “Your body lacks the ability to store vitamin B12.”
B. “You are unable to absorb vitamin B12 from food due to lack of intrinsic factor.”
C. “Oral supplements are too expensive and not as effective.”
D. “The injections are needed until your red blood cell count returns to normal.”
Correct Answer: B.
Pernicious anemia is caused by the loss of intrinsic factor, which is necessary for vitamin B12 absorption in the GI tract.
A nurse is caring for a client with neutropenia due to chemotherapy. Which action by the nurse requires immediate correction?
A. Encouraging the client to eat freshly cooked fruits and vegetables
B. Placing a sign on the door indicating neutropenic precautions
C. Allowing a visitor to bring in fresh flowers
D. Performing hand hygiene before entering the room
Correct Answer: C.
Fresh flowers can harbor bacteria and fungi, posing a serious infection risk to neutropenic clients. They should not be allowed in the room.
A nurse is caring for a client who has a rotator cuff injury. Which of the following activities is most appropriate for the nurse to encourage?
A. Bed rest with the arm immobilized for 72 hours
B. Ice application to the shoulder every hour
C. Range-of-motion exercises to prevent stiffness
D. Heat application to the shoulder to relieve pain
Correct Answer: C.
Range-of-motion exercises are important to prevent stiffness in the shoulder after a rotator cuff injury. Physical therapy may guide the client through safe exercises to improve movement and strength.
A client with polycystic kidney disease is being taught about complication prevention. Which statement by the client indicates a need for further teaching?
A. “I will keep my blood pressure under good control.”
B. “I’ll drink at least 3 liters of fluid each day.”
C. “I can take over-the-counter NSAIDs for aches.”
D. “I’ll report any blood in my urine immediately.”
Correct Answer: C.
NSAIDs can further impair renal perfusion and worsen kidney function in polycystic kidney disease. Clients should use acetaminophen or prescribed alternatives for pain.
A neonate born to a mother with untreated gonorrhea has copious purulent eye discharge at 24 hours of life. What is the nurse’s priority action?
A. Begin erythromycin ophthalmic ointment immediately
B. Obtain a conjunctival culture before treatment
C. Instill saline drops and cleanse the eyes QID
D. Schedule the neonate for an urgent ophthalmology consult
Correct Answer: A. Begin erythromycin ophthalmic ointment immediately
Rationale: Prophylactic newborn eye treatment with erythromycin ointment prevents gonococcal ophthalmia neonatorum, a sight-threatening emergency.*