Nokea
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
- A. Measure oxygen saturation after a 12-minute walk
- B. Verify that the client understands all possible complications
- C. Explain the procedure in detail to the client and the family
- D. Validate that informed consent has been given to the client
Correct Answer: D
Rationale: Validating informed consent is critical before an invasive procedure like thoracentesis to ensure the client is aware of risks and agrees to the procedure. Explaining the procedure and verifying complications are typically the physician's responsibility, and a 12-minute walk is not relevant.
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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.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?
- A. Assistance with activities of daily living
- B. Assess the client's oxygen saturation levels
- C. Oxygen therapy at 2 liters per nasal cannula
- D. Complete bedrest with frequent repositioning
Correct Answer: A
Rationale: Dyspnea with activity intolerance, such as stopping multiple times while climbing stairs, indicates functional limitation (class III). Assistance with activities of daily living supports the client's needs without restricting activity unnecessarily. Oxygen therapy or bedrest may not be indicated unless hypoxia or severe limitation is present.
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercises?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: An equal AP and lateral chest diameter suggests a barrel chest, often associated with chronic airflow limitation conditions like COPD or severe asthma. Asking about chronic breathing problems directly addresses the potential underlying cause. Other options are less relevant to this specific finding.
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 assesses a 66-year-old client who is attempting to quit smoking. The client states, 'I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day.' How many pack-years should the nurse document for this client? Record your answer using a whole number.
- A. 40 pack-years
- B. 45 pack-years
- C. 50 pack-years
- D. 55 pack-years
Correct Answer: B
Rationale: Pack-years are calculated as packs per day multiplied by years smoked. The client smoked 1 pack/day for 40 years (66 - 16 - 10 = 40) and 0.5 pack/day for 10 years. Calculation: (1 ? 40) + (0.5 ? 10) = 40 + 5 = 45 pack-years.