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A client has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
- A. Your urine can turn a dark orange.
- B. Watch for a change in the sclera of your eyes.
- C. Watch for any changes in vision.
- D. Take vitamin B6 daily.
Correct Answer: C
Rationale: Ethambutol is associated with potential vision changes, including optic neuritis. Patients should be instructed to report any visual disturbances immediately to prevent permanent vision loss. Monitoring for changes in vision is crucial to detect any adverse effects early on and prevent serious complications.
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A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
- B. ''I will lie on my back with my knees bent.''
- C. ''I will rest my hand over my abdomen to create resistance.''
- D. ''I will take in a deep breath and hold it before exhaling.''
Correct Answer: D
Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.
When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?
- A. Assess the client's pain.
- B. Obtain a large-bore IV needle for decompression.
- C. Administer lorazepam.
- D. Prepare for chest tube insertion.
Correct Answer: B
Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.
A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?
- A. Take quick breaths upon inhalation.
- B. Place your hand over your stomach.
- C. Take a deep breath in through your nose.
- D. Puff your cheeks upon exhalation.
Correct Answer: C
Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.
A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?
- A. Notify the provider.
- B. Administer heparin via IV infusion.
- C. Administer oxygen therapy.
- D. Obtain a spiral CT scan.
Correct Answer: C
Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.
A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?
- A. Albuterol can increase my blood sugar levels.
- B. Albuterol can decrease my immune response.
- C. I can experience an increase in my heart rate while taking albuterol.
- D. I may develop mouth sores while taking albuterol.
Correct Answer: C
Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.