Nokea
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.
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The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I will only use oxygen when I feel short of breath.
- B. I will store oxygen tanks in a warm, sunny area.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will smoke while wearing my oxygen via nasal cannula.
Correct Answer: C
Rationale: Using cotton balls to cushion oxygen tubing prevents pressure ulcers, indicating correct understanding. Continuous oxygen should be worn at all times, not only when short of breath. Smoking while using oxygen poses a fire risk, and oxygen tanks should be stored in a cool, well-ventilated area.
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
- A. A 46-year-old with a 30-year history of smoking.
- B. A 52-year-old in a tripod position using accessory muscles to breathe.
- C. A 50-year-old with dependent edema and clubbed fingers.
- D. A 74-year-old with a chronic cough and thick, tenacious secretions.
Correct Answer: B
Rationale: A client in a tripod position using accessory muscles is in acute respiratory distress and requires immediate assessment to prevent respiratory failure. The other clients' symptoms, while concerning, do not indicate immediate distress.
A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Strip the tubing to minimize clot formation and ensure patency.
- B. Secure tubing junctions with clamps to prevent accidental disconnections.
- C. Connect the chest tube to wall suction at the level prescribed by the provider.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct Answer: D
Rationale: Keeping padded clamps at the bedside ensures safety if the drainage system is interrupted. Stripping the tubing can cause harm, junctions should be taped not clamped, and suction levels are set per the device manufacturer, not the provider.
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 auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip)
- A. Inflammation of the pleura
- B. Upper airway obstruction
- C. Pulmonary vascular edema
- D. Bronchospasm
Correct Answer: A
Rationale: A pleural friction rub, heard when the pleura is inflamed, is associated with inflammation of the pleura rubbing against the lung wall. Upper airway obstruction causes stridor, pulmonary edema causes crackles, and bronchospasm causes wheezing.