Nokea
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
- A. Client reports being dizzy—nurse calls the Rapid Response Team.
- B. Client's heart rate is 55 beats/min—nurse withholds pain medication.
- C. Client has reduced breath sounds—nurse calls primary health care provider immediately.
- D. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.
Correct Answer: C
Rationale: The correct answer is C. Reduced breath sounds after an open lung biopsy could indicate a potential complication such as pneumothorax, requiring immediate attention. Calling the primary health care provider allows for timely assessment and intervention.
Choice A is incorrect because dizziness alone may not warrant calling the Rapid Response Team without further assessment.
Choice B is incorrect as a heart rate of 55 beats/min may not necessarily indicate a need to withhold pain medication without considering other factors.
Choice D is incorrect as a respiratory rate of 18 breaths/min does not necessarily mean the oxygen flow rate should be decreased without further assessment.
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All of the following provide chemoreceptor input to the respiratory centers of the medulla oblongata except the
- A. olfactory epithelium
- B. medullary chemoreceptors
- C. aortic body
- D. carotid body
Correct Answer: A
Rationale: The correct answer is A: olfactory epithelium. The olfactory epithelium is responsible for detecting smells, not providing chemoreceptor input to the respiratory centers in the medulla oblongata. Medullary chemoreceptors, aortic body, and carotid body are all involved in sensing oxygen, carbon dioxide, and pH levels in the blood, providing crucial input to regulate breathing. The olfactory epithelium is not directly involved in respiratory regulation, making it the exception in this context.
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be ordered to assess for what in this patient?
- A. Alveolar dysfunction
- B. Forced vital capacity
- C. Tidal volume
- D. Chest wall invasion
Correct Answer: D
Rationale: The correct answer is D: Chest wall invasion. An MRI would be ordered to assess for any potential invasion of the chest wall by the suspected bronchogenic carcinoma. MRI provides detailed imaging of soft tissues and can help determine the extent of tumor invasion beyond the lungs.
Explanation:
A: Alveolar dysfunction - Alveolar dysfunction is typically assessed using pulmonary function tests or imaging techniques like CT scans, not MRI.
B: Forced vital capacity - Forced vital capacity is a measure of lung function and is not typically assessed using MRI.
C: Tidal volume - Tidal volume is a measure of the volume of air moved in and out of the lungs during normal breathing and is not assessed using MRI in this context.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient's arterial oxygen saturation (SaO2). What procedure will best accomplish this?
- A. Incentive spirometry
- B. Arterial blood gas (ABG) measurement
- C. Peak flow measurement
- D. Pulse oximetry
Correct Answer: D
Rationale: Step 1: Pulse oximetry is a non-invasive method of measuring SaO2 by using a sensor attached to a patient's fingertip, earlobe, or toe.
Step 2: It provides immediate and continuous monitoring of oxygen saturation levels in the blood, making it an efficient and reliable method.
Step 3: Pulse oximetry is widely used in clinical settings due to its accuracy and convenience.
Step 4: In contrast, the other options are not direct methods for assessing SaO2. Incentive spirometry helps improve lung function, ABG measures blood pH and gases, and peak flow measures airflow in the lungs.
Which of the following instructions should the nurse give a client about his active tuberculosis (TB)?
- A. "It's okay to miss a dose every day or two."
- B. "If side effects occur, stop taking the medication."
- C. "Only take the medication until you feel better."
- D. "You must comply with the medication regimen to treat TB."
Correct Answer: D
Rationale: The correct answer is D because adherence to the medication regimen is crucial in treating active TB to prevent drug resistance and ensure successful treatment. Missing doses can lead to treatment failure and the spread of TB. Option A is incorrect because missing doses compromises treatment effectiveness. Option B is incorrect as stopping medication due to side effects can also result in treatment failure. Option C is incorrect because TB treatment must be completed as prescribed, regardless of symptom improvement.
The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds that the mask fits snugly the skin under the mask and straps is intact and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?
- A. Assess the client's oxygen saturation.
- B. Document these findings in the chart.
- C. Immediately increase the flow rate.
- D. Turn the flow rate down to 2 L/min.
Correct Answer: C
Rationale: The correct answer is C: Immediately increase the flow rate. A flow rate of 3 L/min is inadequate to deliver 50% O2 through a mask. Increasing the flow rate will ensure the client receives the prescribed oxygen concentration.
Incorrect choices:
A: Assess the client's oxygen saturation - This is not the priority as the oxygen delivery is suboptimal.
B: Document these findings in the chart - Documentation is important but addressing the oxygen delivery issue is more critical.
D: Turn the flow rate down to 2 L/min - This would further reduce the oxygen concentration, which is not appropriate in this case.