Nokea
A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Find an activity that you enjoy and will keep your hands busy
- B. Keep snacks like potato chips on hand to nibble on
- C. Identify a punishment for yourself if you backslide
- D. Drink at least eight glasses of water each day
- E. Make a list of reasons you want to stop smoking
Correct Answer: A,D,E
Rationale: Encouraging activities to keep hands busy, staying hydrated, and listing reasons for quitting support smoking cessation. Potato chips are unhealthy snacks, and punishment for backsliding is not constructive.
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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 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.
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 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 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.