Nokea
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds with aids
- C. Productive cough
- D. Incisional discomfort
Correct Answer: B
Rationale: Absent breath sounds may indicate a pneumothorax, a life-threatening complication post-lung biopsy requiring immediate action. Increased temperature, productive cough, and incisional discomfort are not immediately life-threatening.
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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.
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 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 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.
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.