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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.
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A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?
- A. Make a list of reasons why smoking is a bad habit
- B. Rise slowly when getting out of bed in the morning
- C. Smoking while taking this medication will increase your risk of a stroke
- D. Stopping this medication suddenly increases your risk for a heart attack
Correct Answer: C
Rationale: Smoking while using nicotine replacement therapy increases cardiovascular risks, including stroke. The nurse should emphasize avoiding smoking during treatment. Other statements are not directly relevant to nicotine replacement therapy.
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has to exposed your smoking history. Which action is most important for the nurse to take when interviewing this client?
- A. Tell a client that he needs to quit smoking to stop further cancer development
- B. Encourage the client to be completely honest about both tobacco and marijuana use
- C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty
- D. Avoid giving the client false hope regarding cancer treatment and prognosis
Correct Answer: C
Rationale: Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have quit or be in denial about this habit, a nonjudgmental attitude during the interview encourages honesty about exposure. Asking about current or past use and passive exposure is important, but maintaining a nonjudgmental attitude is the priority to facilitate open communication.
While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)
- A. What response do you have when you eat avocados?
- B. I will remove any avocados that are on your food tray
- C. Ask about the last time you ate avocados
- D. I will document this in your record so all of your providers will know
- E. Have you ever been treated for this allergic reaction?
Correct Answer: A,D,E
Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. Oxygen saturation is 92% after a 12-minute walk
- B. A small amount of drainage from the site is noted
- C. Pulse oximetry is 95% on 2 liters of oxygen
- D. The trachea is deviated toward the opposite side of the neck
Correct Answer: D
Rationale: A deviated trachea indicates a tension pneumothorax, a medical emergency requiring immediate intervention. Other findings, such as small drainage or 95% pulse oximetry, are normal or near-normal and do not require urgent action.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an advanced treatment
- B. Notify the Rapid Response Team
- C. Assess the clients peripheral pulses
- D. Obtain blood and sputum cultures
Correct Answer: B
Rationale: Continuous cyanosis despite oxygen therapy suggests methemoglobinemia, a serious adverse effect of benzocaine spray. Notifying the Rapid Response Team is critical for immediate advanced care. Other actions do not address the urgent oxygenation issue.