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A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip)
- A. Assess for airway obstruction.
- B. Initiate oxygen therapy.
- C. Assess vital signs.
- D. Elevate the client's head.
Correct Answer: A
Rationale: Stridor indicates severe airway constriction, requiring immediate assessment for airway obstruction. Administering oxygen, assessing vital signs, or elevating the head are secondary until the airway is addressed.
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A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which pathophysiologic process should the nurse associate with these clinical manifestations?
- A. Increased pulmonary pressure creating a higher workload on the right side of the heart.
- B. Increased pulmonary inflammation of the bronchi and bronchioles.
- C. Increased number and size of mucus glands producing large amounts of thick mucus.
- D. Left ventricular hypertrophy creating a decrease in cardiac output.
Correct Answer: A
Rationale: Smoking can lead to pulmonary hypertension, causing cor pulmonale (right-sided heart failure). This results in increased pulmonary pressure, backing up blood into the right heart and peripheral venous system, leading to distended neck veins and edema. The other options describe different pathophysiological processes not directly linked to these symptoms.
The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, 'The medication is too expensive to use every day. I only use my inhaler when I have an attack.' How should the nurse respond?
- A. You are using the inhaler incorrectly. This medication should be taken daily.
- B. If you avoid environmental stimuli, it will be okay to use the inhaler only for asthma attacks.
- C. Tell me more about your fears related to feelings of breathlessness.
- D. It is important to use this type of inhaler every day. Let's identify potential community services to help you.
Correct Answer: D
Rationale: Long-acting beta2 agonists are maintenance medications to prevent asthma attacks and should be used daily. Addressing the client's financial concerns by identifying community resources is the most effective response. Simply stating the inhaler is used incorrectly or exploring fears does not address the financial barrier.
A nurse is teaching a client with cystic fibrosis (CF). Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Drink fluids with meals to stay hydrated.
- B. Rest before meals to conserve energy.
- C. Eat six small meals a day.
- D. Eat high-fiber foods to promote gastric emptying.
- E. Increase carbohydrate intake for energy.
Correct Answer: A,B,C
Rationale: Fluids should be avoided with meals to prevent bloating, resting before meals conserves energy, and six small meals reduce bloating. High-fiber foods can cause gas, worsening shortness of breath, and excessive carbohydrates increase carbon dioxide production, risking acidosis.
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.
The nurse is caring for a client with lung cancer who states, 'I don't want any pain medication because I am afraid to become addicted.' How should the nurse respond?
- A. I will ask the provider to change your medication to a drug that is less potent.
- B. I will ask the provider to prescribe a non-opioid analgesic.
- C. It is unlikely you will become addicted when taking medicine for pain.
- D. I will discuss alternative pain relief methods like acupuncture.
Correct Answer: C
Rationale: The risk of addiction is low when pain medications are used appropriately for pain management in clients with cancer. Changing to a less potent drug or non-opioid may not adequately address pain. Alternative methods like acupuncture may be considered but are not the priority response.