A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?
- A. Production of pink sputum
- B. Tracheal deviation
- C. Drainage greater than 70 mL/hr
- D. Sudden onset of shortness of breath
Correct Answer: B
Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent respiratory compromise. The other choices are incorrect because:
A: Production of pink sputum may indicate bleeding but does not require immediate intervention unless severe.
C: Drainage greater than 70 mL/hr may indicate a potential issue with the chest tube, but it does not require immediate intervention unless accompanied by other symptoms.
D: Sudden onset of shortness of breath is concerning but not as immediately life-threatening as tracheal deviation in this context.
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Clients with mitral stenosis would likely manifest findings associated with congestion in the:
- A. Pulmonary circulation.
- B. Descending aorta.
- C. Superior vena cava.
- D. Bundle of His.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?
- A. I will use my peak flow meter every morning.
- B. I will use my peak flow meter when I feel short of breath.
- C. I will use my peak flow meter before using my inhaler.
- D. I will use my peak flow meter after using my inhaler.
Correct Answer: A
Rationale: The correct answer is A because using the peak flow meter every morning provides a baseline measurement of lung function when the client is typically stable. This allows for early detection of changes and adjustment of treatment. Choice B is incorrect as waiting until feeling short of breath may be too late. Choice C is incorrect because using the peak flow meter before the inhaler may not provide an accurate measurement. Choice D is incorrect as using the peak flow meter after the inhaler may not reflect the true lung function.
During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Decreased breath sounds
- D. Productive cough
Correct Answer: C
Rationale: The correct answer is C: Decreased breath sounds. This finding indicates worsening asthma as it signifies decreased airflow to the lungs, which can lead to inadequate oxygenation. Loud wheezing (A) is common in asthma but does not necessarily indicate worsening. Increased respiratory rate (B) is a compensatory mechanism to improve oxygenation. Productive cough (D) may indicate clearing of mucus and is not necessarily associated with worsening asthma.
A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
- A. I will take my medication as prescribed.
- B. I will need to have regular follow-up chest x-rays.
- C. I will be able to return to work immediately.
- D. I will use tissues to cover my mouth when I cough.
Correct Answer: C
Rationale: The correct answer is C because a client with TB should not return to work immediately due to the risk of spreading the infection. Taking medication as prescribed (A), having regular follow-up chest x-rays (B), and using tissues to cover the mouth when coughing (D) are all important aspects of managing TB and preventing its spread. Returning to work immediately can put coworkers at risk of contracting TB. Therefore, the client should understand the importance of taking precautions and following healthcare provider recommendations to ensure proper treatment and prevent transmission of the disease.
You are teaching prevention of accidental eye injuries in a community health clinic to a church group. What is the most important thing to stress?
- A. Follow workplace policies for handling chemicals.
- B. Children and parents should be cautious about aggressive play.
- C. Wear protective eyewear during sports or hazardous work.
- D. Establish emergency eyewash stations in the workplace.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.