Nokea
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
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The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
- A. Taking the client's temperature
- B. Assessing the client's blood pressure
- C. Monitoring the client's respiratory status
- D. Checking the client's pupillary response
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: B
Rationale: Patients with latent tuberculosis are not contagious and have no symptoms, but during procedures like bronchoscopy that may generate aerosols, a surgical mask is worn to prevent potential spread if the infection is active.
You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material?
- A. I'll use hand sanitizer regularly while I'm out in public.'
- B. It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia.'
- C. I will try to avoid large crowds of people during the peak of flu season.'
- D. It is important I try to quit smoking.'
Correct Answer: B
Rationale: The statement about not receiving the Pneumovax vaccine is incorrect, as vaccination is recommended to prevent pneumococcal pneumonia, and prior infection doesn't confer immunity. Other options reflect correct preventive measures.