Nokea
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.
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A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?
- A. Instruct the client to wash their hands after contact with other people.
- B. Implement Droplet Precautions and don a surgical mask.
- C. Isolate the client from other clients with cystic fibrosis.
- D. Obtain blood, sputum, and urine culture specimens.
Correct Answer: C
Rationale: Burkholderia cepacia is spread through casual contact among cystic fibrosis clients, necessitating isolation from other CF clients. Hand washing is important but not the priority. Droplet precautions are not required, and cultures are secondary to preventing transmission.
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 who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?
- A. Spaghetti with meat sauce, ice cream
- B. Grilled cheese sandwich with whole wheat bread
- C. Oatmeal with skim milk, custard
- D. Pasta salad, custard, orange juice
Correct Answer: C
Rationale: Side effects of radiation therapy may include esophagitis. Oatmeal with skim milk and custard are soft, non-irritating foods suitable for a client with esophagitis. Spaghetti with meat sauce may be too spicy, grilled cheese sandwiches are too difficult to swallow, and orange juice is too caustic due to its citric acid content.
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 is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching?
- A. Take an antibiotic each day.
- B. Contact your provider to obtain genetic screening.
- C. Eat a well-balanced, nutritious diet.
- D. Perform daily respiratory therapy exercises.
Correct Answer: C
Rationale: Clients with CF often experience malnourishment due to vitamin deficiency and pancreatic malfunction. A well-balanced, nutritious diet is essential for maintaining health. Daily antibiotics are not typically required, genetic screening is not relevant for management, and while respiratory therapy is important, it is not listed as an option.