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A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD?
- A. Emphysema
- B. Pneumonia
- C. Chronic bronchitis
- D. Pneumothorax
Correct Answer: C
Rationale: Chronic bronchitis , a type of COPD, is characterized by chronic productive cough, hypoxemia, hypercapnia, cyanosis, and edema from right heart failure. Emphysema typically shows barrel chest, pneumonia is an infection, and pneumothorax involves lung collapse.
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The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
- A. The client diagnosed with congestive heart failure.
- B. The client with a documented allergy to eggs.
- C. The client who has had an anaphylactic reaction to penicillin.
- D. The client who has an elevated blood pressure and pulse.
Correct Answer: B
Rationale: Influenza vaccines are often grown in eggs, making egg allergy (B) a contraindication due to anaphylaxis risk. Congestive heart failure (A), penicillin allergy (C), and elevated vitals (D) are not contraindications for the flu vaccine.
Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
- A. The patient reports pain when the foot is manually dorsiflexed.
- B. The patient reports pain when the foot is manually plantarflexed.
- C. The patient experiences pain when the leg is extended.
- D. the patient experiences pain when the leg is flexed.
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates more teaching is required?
- A. It doesn't matter if I smoke now. I already have cancer.
- B. I should see the oncologist at my scheduled appointment.
- C. If I begin to run a fever, I should notify the HCP.
- D. I should plan for periods of rest throughout the day.
Correct Answer: A
Rationale: Continued smoking (A) worsens lung cancer outcomes, indicating a need for teaching. Follow-ups (B), fever reporting (C), and rest (D) are correct.
Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply:
- A. A 53 year old female recovering from abdominal surgery.
- B. A 69 year old patient who recently received the pneumococcal conjugate vaccine.
- C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula.
- D. A 8 month old with RSV (respiratory syncytial virus) infection.
Correct Answer: A,C,D
Rationale: Patients recovering from surgery are at risk due to immobility and impaired cough reflex, those with COPD have chronic lung disease increasing susceptibility, and infants with RSV are prone to secondary bacterial pneumonia. The vaccinated patient has reduced risk due to immunity.
Which time of day is best for the nurse to obtain a sputum specimen from the client?
- A. Before bedtime
- B. After a meal
- C. Between meals
- D. On awakening
Correct Answer: D
Rationale: Sputum is most concentrated and easier to collect on awakening due to accumulation overnight.