Nokea
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. Oxygen saturation is 92% after a 12-minute walk
- B. A small amount of drainage from the site is noted
- C. Pulse oximetry is 95% on 2 liters of oxygen
- D. The trachea is deviated toward the opposite side of the neck
Correct Answer: D
Rationale: A deviated trachea indicates a tension pneumothorax, a medical emergency requiring immediate intervention. Other findings, such as small drainage or 95% pulse oximetry, are normal or near-normal and do not require urgent action.
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A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an advanced treatment
- B. Notify the Rapid Response Team
- C. Assess the clients peripheral pulses
- D. Obtain blood and sputum cultures
Correct Answer: B
Rationale: Continuous cyanosis despite oxygen therapy suggests methemoglobinemia, a serious adverse effect of benzocaine spray. Notifying the Rapid Response Team is critical for immediate advanced care. Other actions do not address the urgent oxygenation issue.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
- A. Encourage the client to increase fluid intake
- B. Assess the clients level of consciousness
- C. Raise the head of the bed to at least 45 degrees
- D. Provide the client with humidified oxygen
Correct Answer: B
Rationale: Assessing the client's level of consciousness is critical as it indicates how the client is responding to the infection and its impact on overall health. While encouraging fluid intake, raising the head of the bed, and providing humidified oxygen are important interventions, they are secondary to assessing consciousness, which can reveal urgent changes in the client's condition.
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercises?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: An equal AP and lateral chest diameter suggests a barrel chest, often associated with chronic airflow limitation conditions like COPD or severe asthma. Asking about chronic breathing problems directly addresses the potential underlying cause. Other options are less relevant to this specific finding.
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which findings should the nurse identify as adverse effects of this medication? (Select all that apply.)
- A. Visual hallucinations
- B. Tachycardia
- C. Decreased cravings
- D. Impaired judgment
- E. Increased thirst
Correct Answer: A,D
Rationale: Varenicline has a black box warning for causing behavioral changes, including visual hallucinations and impaired judgment. Tachycardia and increased thirst are not associated adverse effects, while decreased cravings is a desired therapeutic effect.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
- A. Measure oxygen saturation after a 12-minute walk
- B. Verify that the client understands all possible complications
- C. Explain the procedure in detail to the client and the family
- D. Validate that informed consent has been given to the client
Correct Answer: D
Rationale: Validating informed consent is critical before an invasive procedure like thoracentesis to ensure the client is aware of risks and agrees to the procedure. Explaining the procedure and verifying complications are typically the physician's responsibility, and a 12-minute walk is not relevant.