Nokea
A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to:
- A. prevent excessive drying of secretions.
- B. facilitate oxygen diffusion of the blood.
- C. prevent depression of the respiratory drive.
- D. compensate for increased airway resistance.
Correct Answer: C
Rationale: In COPD, low oxygen levels drive respiration. Low-flow oxygen prevents suppression of the respiratory drive, which could occur with high-flow oxygen.
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After a chest tube has been inserted to treat the client's pneumothorax, which finding indicates that the chest tube is functioning correctly?
- A. The water in the suction control chamber is bubbling.
- B. The water seal chamber has continuous vigorous bubbling.
- C. The drainage system is positioned upright.
- D. The client reports relief of chest pain.
Correct Answer: D
Rationale: Relief of chest pain indicates the chest tube is effectively re-expanding the lung and resolving the pneumothorax.
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: Active tuberculosis requires airborne precautions due to its transmission via respiratory droplets. A respirator (e.g., N95) is required for healthcare workers, not a surgical mask, to protect against inhaling the bacteria.
Which nursing assessment data support that the client has experienced a pulmonary embolism?
- A. Calf pain with dorsiflexion of the foot.
- B. Sudden onset of chest pain and dyspnea.
- C. Left-sided chest pain and diaphoresis.
- D. Bilateral crackles and low-grade fever.
Correct Answer: B
Rationale: Sudden chest pain and dyspnea (B) are classic PE symptoms from hypoxia. Calf pain (A) suggests DVT, left-sided pain (C) suggests MI, and crackles/fever (D) suggest pneumonia.
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.