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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.
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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 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.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
- A. When the tube drainage increases and warms to the touch.
- B. When the tube drainage decreases and becomes sanguineous.
- C. When the client experiences pain at the insertion site.
- D. When the tube becomes disconnected from the drainage system.
Correct Answer: D
Rationale: A disconnected chest tube allows air to enter the pleural space due to negative intrathoracic pressure, causing a pneumothorax. Warm drainage, sanguineous drainage, or pain at the insertion site do not directly increase pneumothorax risk.
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for tracheal deviation.
- C. Perform peak expiratory flow readings.
- D. Administer prescribed albuterol (Proventil) inhaler.
- E. Encourage diaphragmatic breathing.
Correct Answer: C,D
Rationale: Suprasternal retraction and wheezing indicate acute asthma exacerbation. Administering albuterol (a short-acting beta2 agonist) is appropriate for immediate relief, and peak flow readings help assess severity. Salmeterol is a long-acting medication, not for acute attacks. Tracheal deviation is unrelated, and diaphragmatic breathing is not a priority during an acute attack.
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?
- A. I will carry this medication with me at all times in case I need it.
- B. I will take this medication when I start to experience an asthma attack.
- C. I will take this medication every morning to help prevent an acute attack.
- D. I will be weaned off this medication when I no longer need it.
Correct Answer: C
Rationale: Long-acting beta2 agonist medications are used to prevent asthma attacks due to their long-acting nature. The client should take this medication daily for best effect. It is not a rescue medication, so it does not need to be carried at all times or used during an attack. Clients are not typically weaned off this medication as it is likely a daily maintenance therapy.