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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.
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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.
The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. Press down firmly on the canister to release one dose of medication. 2. Breathe in slowly and deeply. 3. Shake the whole unit vigorously three or four times. 4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 5. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. 6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
- A. 2,3,5,1,6,2
- B. 3,4,5,1,2,6
- C. 4,3,5,1,2,6
- D. 1,3,2,5,6,7,4
Correct Answer: C
Rationale: The correct order is: insert the inhaler into the spacer (4), shake the unit (3), place the mouthpiece in the mouth (5), release the medication (1), breathe in slowly and deeply (2), and hold the breath for 10 seconds (6).
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.
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.
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.