Nokea
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.
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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.
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 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 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 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.