Nokea
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
- A. You will not be able to eat or drink after the procedure until you are able to cough.
- B. You will need to take deep breaths through your nose during the procedure.
- C. The procedure is painful
- D. and sedation will not be used.
- E. You will need to stay on bed rest for 24 hours after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should include the statement "You will not be able to eat or drink after the procedure until you are able to cough" because it is essential for the client's safety to prevent aspiration. After a bronchoscopy, the client may have an impaired gag reflex from the procedure, increasing the risk of choking. Therefore, it is crucial to wait until the gag reflex returns before eating or drinking. This statement emphasizes the importance of airway protection post-procedure.
Summary:
B: Incorrect - Breathing during a bronchoscopy is usually done through the mouth.
C: Incorrect - Bronchoscopy is uncomfortable but not typically painful due to sedation.
D: Incorrect - Sedation is commonly used during bronchoscopy to ensure client comfort.
E: Incorrect - Bed rest after a bronchoscopy is not typically necessary unless complications arise.
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A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
- A. Depress the canister after you inhale.'
- B. Exhale fully before bringing the inhaler to your lips.'
- C. Use peroxide to clean the mouthpiece of your inhaler.'
- D. Do not shake your inhaler before use.'
Correct Answer: B
Rationale: The correct answer is B: "Exhale fully before bringing the inhaler to your lips." This statement is important because exhaling fully before inhaling the medication helps to ensure maximum delivery of the medication into the lungs. By exhaling fully, the client creates more space in the lungs for the medication to reach the lower airways effectively.
Choice A is incorrect because depressing the canister after inhaling would not allow the medication to reach the lungs. Choice C is incorrect as peroxide is not recommended for cleaning inhaler mouthpieces. Choice D is incorrect because shaking the inhaler before use is necessary to ensure proper mixing of the medication for effective delivery.
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
- A. Limit the client's fluid intake.
- B. Measure blood glucose every 2 hr.
- C. Instruct the client to expect tingling in their extremities.
- D. Instruct the client to lie flat.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to lie flat. This is important to prevent post-lumbar puncture headache by promoting the closure of the dural puncture site. Lying flat helps reduce the risk of cerebrospinal fluid leakage and subsequent headache. Limiting fluid intake (A) is not necessary post-lumbar puncture. Monitoring blood glucose (B) is not directly related to lumbar puncture care. Expecting tingling in extremities (C) is not a common post-lumbar puncture symptom.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
- E. Oxygen saturation 93% on room air
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding suggests cardiac distress or arrhythmia, which could indicate a heart attack. Immediate follow-up is necessary to assess the client's cardiac status and intervene promptly.
Incorrect choices:
A: Temperature within normal range.
C: Respiratory rate within normal range.
D: Blood pressure slightly elevated but not an immediate concern.
E: Oxygen saturation slightly low but not critically low.