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A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first?
- A. Document the findings
- B. Administer oxygen therapy
- C. Position the client in high-Fowler's position
- D. Administer prescribed albuterol
Correct Answer: A
Rationale: Harsh, hollow sounds over the trachea and larynx are normal breath sounds. The nurse should document this finding. No interventions like oxygen, positioning, or albuterol are necessary for a normal finding.
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A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
- A. Measure oxygen saturation after a 12-minute walk
- B. Verify that the client understands all possible complications
- C. Explain the procedure in detail to the client and the family
- D. Validate that informed consent has been given to the client
Correct Answer: D
Rationale: Validating informed consent is critical before an invasive procedure like thoracentesis to ensure the client is aware of risks and agrees to the procedure. Explaining the procedure and verifying complications are typically the physician's responsibility, and a 12-minute walk is not relevant.
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Encourage deep breathing and coughing
- B. Implement an air mattress overlay
- C. Ambulate the client three times each day
- D. Provide a diet high in protein and vitamins
- E. Administer acetaminophen (Tylenol) twice daily
Correct Answer: A,C,D
Rationale: Deep breathing and coughing, ambulation, and a nutrient-rich diet promote respiratory health and prevent infection. An air mattress overlay is for pressure relief, not respiratory health, and acetaminophen does not reduce infection risk.
A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, 'I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day.' How many pack-years should the nurse document for this client? Record your answer using a whole number.
- A. 40 pack-years
- B. 45 pack-years
- C. 50 pack-years
- D. 55 pack-years
Correct Answer: B
Rationale: Pack-years are calculated as packs per day multiplied by years smoked. The client smoked 1 pack/day for 40 years (66 - 16 - 10 = 40) and 0.5 pack/day for 10 years. Calculation: (1 ? 40) + (0.5 ? 10) = 40 + 5 = 45 pack-years.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
- A. Encourage the client to increase fluid intake
- B. Assess the clients level of consciousness
- C. Raise the head of the bed to at least 45 degrees
- D. Provide the client with humidified oxygen
Correct Answer: B
Rationale: Assessing the client's level of consciousness is critical as it indicates how the client is responding to the infection and its impact on overall health. While encouraging fluid intake, raising the head of the bed, and providing humidified oxygen are important interventions, they are secondary to assessing consciousness, which can reveal urgent changes in the client's condition.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)
- A. Withhold bronchodilator medication
- B. The client is ready to go down to radiology for this examination
- C. Physical therapy states the client can run on a treadmill
- D. The client has not smoked in the last 6 hours
- E. The client is alert and can follow your commands
Correct Answer: A,D,E
Rationale: Withholding bronchodilators, confirming no recent smoking, and ensuring the client can follow commands are essential for accurate PFTs. PFTs are performed at the bedside, not in radiology, and a treadmill is not used.