Nokea
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Sudden onset of shortness of breath
- D. Pain at insertion site
- E. Drainage of 75 ml/hr
Correct Answer: C,E
Rationale: Sudden shortness of breath and tracheal deviation indicate a pneumothorax, requiring immediate intervention. Pink sputum, pain at the insertion site, and drainage of 75 ml/hr are not immediately life-threatening.
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After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?
- A. I will carry this medication with me at all times in case I need it.
- B. I will take this medication when I start to experience an asthma attack.
- C. I will take this medication every morning to help prevent an acute attack.
- D. I will be weaned off this medication when I no longer need it.
Correct Answer: C
Rationale: Long-acting beta2 agonist medications are used to prevent asthma attacks due to their long-acting nature. The client should take this medication daily for best effect. It is not a rescue medication, so it does not need to be carried at all times or used during an attack. Clients are not typically weaned off this medication as it is likely a daily maintenance therapy.
A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
- A. Review the client's pulmonary function test results.
- B. Review medications the client is currently taking.
- C. Assess how frequently the client uses a bronchodilator.
- D. Consider the report of the client with asthma phases.
Correct Answer: B
Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people due to increased production of leukotrienes when aspirin or NSAIDs suppress other inflammatory pathways. This is a high-priority action given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. Assessing bronchodilator use addresses interventions for attacks but not their cause. Considering asthma phases is not a priority action.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching?
- A. The client lays on his or her side with knees bent.
- B. The client places his or her hands on his or her abdomen.
- C. The client lays in a prone position with his or her legs straight.
- D. The client places his or her hands above his or her head.
Correct Answer: B
Rationale: To perform diaphragmatic breathing correctly, the client should place their hands on their abdomen to feel the rise and fall of the diaphragm. This type of breathing cannot be performed effectively while lying on the side, in a prone position, or with hands above the head.
A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?
- A. There are a variety of support groups for people who have COPD.
- B. I will ask your provider to prescribe an antianxiety agent.
- C. Friends can be a good support system for clients with chronic disorders.
- D. Encourage the client to participate in social activities.
Correct Answer: A
Rationale: Many clients with moderate to severe COPD become socially isolated due to embarrassment from frequent coughing and mucus production or fatigue. Suggesting a support group addresses this issue by connecting the client with others who share similar experiences. Antianxiety agents or encouraging social activities without addressing the underlying cause are less effective.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
- A. Encourage rinsing the mouth after fluticasone administration.
- B. Obtain an oral specimen for culture and sensitivity.
- C. Start the client on a broad-spectrum antibiotic.
- D. Document the finding as a known side effect.
Correct Answer: A
Rationale: Fluticasone reduces local immunity, increasing the risk of oral infections like Candida albicans. Rinsing the mouth after inhaler use decreases this risk. Obtaining a culture, starting antibiotics, or only documenting the finding do not address prevention or immediate management.