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A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
- A. Purpose of antibiotic therapy
- B. Ways to limit oral fluid intake
- C. Appropriate use of cough suppressants
- D. Safety concerns with home oxygen therapy
Correct Answer: C
Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.
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A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment finding should the nurse immediately report to the health care provider?
- A. Patient is claustrophobic.
- B. Patient is allergic to shellfish.
- C. Patient recently used a bronchodilator inhaler.
- D. Patient is not able to remove a wedding band.
Correct Answer: B
Rationale: The correct answer is that the patient is allergic to shellfish. This is crucial because the contrast media used in CT scans is iodine-based, and individuals with iodine allergies, such as those allergic to shellfish, are at risk of adverse reactions. It is important to identify and address this allergy to prevent potential complications. The other options do not directly impact the safety or effectiveness of the CT scan with contrast media. Claustrophobia can be managed with patient support, the recent use of a bronchodilator inhaler does not typically affect the CT procedure, and not being able to remove a wedding band is not a critical concern for the scan itself.
The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?
- A. I will make an appointment to see the doctor every year.
- B. I will stop taking the prednisone if I experience a dry cough.
- C. I will not worry if I feel a little short of breath with exercise.
- D. I will call the health care provider right away if I develop a fever.
Correct Answer: D
Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
- A. Inspiratory crackles at the bases
- B. Expiratory wheezes in both lungs
- C. Abnormal lung sounds in the apices of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: A
Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.
A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
- A. Position the patient so that the left chest is dependent
- B. Tape a nonporous dressing on three sides over the chest wound
- C. Cover the sucking chest wound firmly with an occlusive dressing
- D. Keep the head of the patient's bed at no more than 30 degrees elevation
Correct Answer: B
Rationale: The correct initial action for a patient with an open stab wound to the chest is to tape a nonporous dressing on three sides over the chest wound. This dressing technique allows air to escape during expiration but prevents air from entering the pleural space during inspiration, helping to prevent tension pneumothorax. Placing the patient so that the left chest is dependent or covering the wound with an occlusive dressing can trap air in the pleural space, leading to tension pneumothorax. Keeping the head of the bed elevated at 30 to 45 degrees helps facilitate breathing and is not the first action to take when managing an open chest wound.