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A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?
- A. Bradypnea
- B. Pleural friction rub
- C. Petechiae
- D. Tachycardia
Correct Answer: A
Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.
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A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?
- A. Tachypnea
- B. Deviation of the trachea
- C. Bradycardia
- D. Pleuritic pain
Correct Answer: C
Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.
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 nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
- A. This medication is given to treat infection.
- B. This medication is given to facilitate ventilation.
- C. This medication is given to decrease inflammation.
- D. This medication is given to reduce anxiety.
Correct Answer: B
Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.
When educating a client who experienced a pneumothorax, which of the following statements should the nurse use?
- A. Notify the provider if you experience weakness.
- B. You should be able to return to work in 1 week.
- C. You need to wear a mask when in crowded areas.
- D. Notify your provider if you experience a productive cough.
Correct Answer: D
Rationale: After experiencing a pneumothorax, it is crucial for the client to be educated on potential complications. A productive cough can indicate infection or another issue, requiring prompt medical attention. Weakness, returning to work, and wearing a mask in crowded areas are important considerations but not as critical as monitoring for respiratory symptoms post-pneumothorax.
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.