Nokea
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: Streptomycin can cause ototoxicity, leading to symptoms like ringing in the ears (tinnitus). This requires immediate physician notification to prevent further hearing damage.
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When performing the client's tracheostomy care, which nursing action is correct?
- A. Cut a gauze square to fit around the client's stoma.
- B. Secure the ties at the back of the client's neck.
- C. Attach new ties before removing old ones.
- D. Replace the cannula after changing the ties.
Correct Answer: C
Rationale: Attaching new ties before removing old ones ensures the tracheostomy tube remains secure, preventing accidental dislodgement.
The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions?
- A. Telling the client to take deep breaths
- B. Striking the back with a cupped hand
- C. Applying pressure below the diaphragm
- D. Placing the client in a sitting position
Correct Answer: B
Rationale: Striking the back with a cupped hand (percussion) helps loosen secretions during postural drainage.
Because of this client's impaired speech, which nursing action facilitates communication?
- A. Discourage the client's attempts at communication.
- B. Inform the client to speak slowly when talking.
- C. Listen attentively to the client's vocalizations.
- D. Provide the client with paper and pencil.
Correct Answer: D
Rationale: Providing paper and pencil allows the client with impaired speech post-laryngectomy to communicate effectively through writing.
The nurse is preparing the plan of care for the client who had a pleurodesis. Which collaborative intervention should the nurse include?
- A. Monitor the amount and color of drainage from the chest tube.
- B. Perform a complete respiratory assessment every two (2) hours.
- C. Administer morphine sulfate, an opioid analgesic, intravenously.
- D. Keep a sterile dressing and bottle of sterile normal saline at the bedside.
Correct Answer: A
Rationale: Pleurodesis involves sclerosing the pleural space to prevent fluid reaccumulation, often requiring a chest tube. Monitoring drainage amount and color (A) is a collaborative intervention to assess procedure success and detect complications. Respiratory assessment (B) and morphine administration (C) are nursing or medical orders, not collaborative. Keeping sterile supplies (D) is preparatory, not a primary intervention.