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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.
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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.
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.
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 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.