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A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
- A. Call the physician and request a prescription for food and water.
- B. Provide the client with ice chips instead of a drink of water.
- C. Assess the client's gag reflex before giving any food or water.
- D. Let the client have a small sip to see whether he or she can swallow.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Assessing the client's gag reflex is crucial after a bronchoscopy to prevent aspiration.
2. Gag reflex helps protect the airway from foreign substances entering the lungs.
3. Providing food or water without assessing the gag reflex can lead to aspiration pneumonia.
4. It is essential to ensure the client's safety before allowing any intake post-bronchoscopy.
Summary:
A: Calling the physician for a prescription is not necessary at this immediate stage.
B: Ice chips may still pose a risk if the client cannot protect their airway.
D: Allowing a sip without assessing gag reflex may lead to aspiration.
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A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?
- A. Limiting fluid.
- B. Having the client take deep breaths.
- C. Asking the client to spit into the collection container.
- D. Asking the client to obtain the specimen after eating.
Correct Answer: B
Rationale: The correct answer is B: Having the client take deep breaths. This action facilitates obtaining a sputum specimen by helping the client to cough and expectorate sputum effectively. Deep breaths help to mobilize secretions, making it easier for the client to produce a quality specimen. Limiting fluid intake (choice A) can lead to dehydration and thickening of secretions, making it harder to obtain a specimen. Asking the client to spit into the container (choice C) may result in contamination with saliva. Asking the client to obtain the specimen after eating (choice D) can introduce food particles into the specimen, affecting the accuracy of the test.
When instructing the client with chronic stable angina it should be emphasized that angina may be brought on by many precipitating factors including the following:
- A. Rest
- B. Sudden change in position
- C. Severe depression
- D. Consumption of a heavy meal
Correct Answer: D
Rationale: Step 1: Consumption of a heavy meal can lead to increased blood flow to the digestive system, causing a temporary reduction in blood flow to the heart muscle.
Step 2: This reduction can trigger angina symptoms in individuals with chronic stable angina.
Step 3: Emphasizing this to the client helps in understanding potential triggers to manage their condition effectively.
Step 4: Rest (A) is usually recommended to relieve angina, sudden change in position (B) is not a common trigger, and severe depression (C) can exacerbate angina but is not a direct precipitating factor like heavy meals.
What is the purpose of treatment with amantadine (Symmetrel)?
- A. To prevent viral pneumonia if taken regularly.
- B. To prevent avian flu if taken at the first signs and symptoms of disease.
- C. To lessen the severity of type A flu symptoms if taken within 48 hours of exposure.
- D. To reduce irritation of bronchitis if taken weekly.
Correct Answer: C
Rationale: Rationale:
1. Amantadine is an antiviral medication effective against type A influenza virus.
2. By taking it within 48 hours of exposure, it can lessen flu symptoms by inhibiting viral replication.
3. It does not prevent pneumonia or avian flu specifically.
4. It is not used for reducing bronchitis irritation.
Summary:
Amantadine is specifically used to reduce the severity of type A flu symptoms when taken within 48 hours of exposure. It is not for prevention of viral pneumonia, avian flu, or bronchitis irritation.
How many lobes does each lung have, and which lung has a cardiac notch?
- A. right lung has 2 lobes, the left lung has 3 lobes; the right lung has a cardiac notch
- B. right lung has 3 lobes, the left lung has 2 lobes; the right lung has a cardiac notch
- C. right lung has 2 lobes, the left lung has 3 lobes; the left lung has a cardiac notch
- D. right lung has 3 lobes, the left lung has 2 lobes; the left lung has a cardiac notch
Correct Answer: D
Rationale: Step 1: Identifying lobes - The right lung has 3 lobes (upper, middle, lower) while the left lung has 2 lobes (upper, lower).
Step 2: Cardiac notch - The cardiac notch is a concave space on the left lung where the heart lies. Therefore, the left lung has a cardiac notch.
Step 3: Correct choice - Option D states that the right lung has 3 lobes, the left lung has 2 lobes, and the left lung has a cardiac notch, which aligns with the anatomical features of the lungs.
Step 4: Incorrect choices - Choices A, B, and C have incorrect combinations of lobes and the presence of a cardiac notch, making them incorrect.
Which lifestyle modification is recommended for individuals with heart failure?
- A. Sedentary lifestyle
- B. Smoking
- C. Regular physical activity
- D. Excessive alcohol consumption
Correct Answer: C
Rationale: The correct answer is C: Regular physical activity. Physical activity is recommended for individuals with heart failure as it can help improve cardiovascular health, strengthen the heart muscle, and enhance overall well-being. Exercise can also help manage symptoms of heart failure and improve quality of life.
The other choices are incorrect:
A: Sedentary lifestyle can worsen heart failure symptoms and lead to deconditioning.
B: Smoking is harmful for heart health and can exacerbate heart failure.
D: Excessive alcohol consumption can weaken the heart muscle and contribute to heart failure complications.