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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.
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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.
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which findings should the nurse identify as adverse effects of this medication? (Select all that apply.)
- A. Visual hallucinations
- B. Tachycardia
- C. Decreased cravings
- D. Impaired judgment
- E. Increased thirst
Correct Answer: A,D
Rationale: Varenicline has a black box warning for causing behavioral changes, including visual hallucinations and impaired judgment. Tachycardia and increased thirst are not associated adverse effects, while decreased cravings is a desired therapeutic effect.
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 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.
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate
- B. Crackles are heard in the trachea. The nurse encourages the client to cough perfectly
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply
Correct Answer: C
Rationale: Wheezes indicate narrowed airways, and an inhaled bronchodilator is the appropriate intervention to open air passages. Hollow sounds over the trachea are normal, crackles may require diuresis rather than coughing, and vesicular sounds in the periphery are normal, requiring no intervention.