Nokea
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.
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The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.
The nurse is preparing to administer scheduled vaccines to a 15-month-old client with Kawasaki disease. The client received IV immunoglobulin 2 months ago. Which of the following vaccines should be delayed? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis B
- C. Measles, mumps, and rubella
- D. Pneumococcal conjugate
- E. Varicella
Correct Answer: C,E
Rationale: MMR and varicella are live vaccines, which should be delayed 11 months post-IVIG due to antibody interference. Hib , hepatitis B , and pneumococcal are not affected.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the charge nurse.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
Which of the following cutaneous manifestations is associated with Lyme disease?
- A. Annular rash
- B. Papular crusts
- C. Bullae
- D. Plaques
Correct Answer: A
Rationale: Lyme disease is characterized by an annular (erythema migrans) rash, often with a bull's-eye appearance, at the site of the tick bite.