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A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Teach the patient about the need for fluid intake.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct Answer: A
Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.
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A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should
- A. assess for the presence of chest pain.
- B. inquire about urinary tract problems.
- C. inspect the skin for rashes or discoloration.
- D. ask the patient about any increase in libido.
Correct Answer: B
Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.
A patient with stage I nonsmall cell lung cancer expresses a preference for chemotherapy over surgery. Which response by the nurse is most appropriate?
- A. Are you concerned about the potential pain from surgery?
- B. Have you had negative experiences with previous surgeries?
- C. Surgery is the recommended treatment for stage I lung cancer.
- D. Tell me about your understanding of the different available treatments.
Correct Answer: D
Rationale: The most appropriate response by the nurse in this situation is to gather more information about the patient's concerns and preferences. By asking the patient to share their understanding of the available treatments, the nurse encourages open communication and gains insight into the patient's knowledge and preferences. Option A focuses solely on pain, which may not be the patient's primary concern. Option B assumes negative experiences without exploring the patient's current thoughts. Option C, stating that surgery is the recommended treatment, dismisses the patient's preference and does not address their concerns. Chemotherapy is not the primary treatment for nonsmall cell lung cancer; it may be used for nonresectable tumors or as adjuvant therapy to surgery, making it crucial for the nurse to explore the patient's treatment preferences and understanding.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
- A. Ask the patient to lie down to complete a full physical assessment.
- B. Briefly ask specific questions about this episode of respiratory distress.
- C. Complete the admission database to check for allergies before treatment.
- D. Delay the physical assessment to first complete pulmonary function tests.
Correct Answer: B
Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
- A. Inadequate tissue perfusion leading to nerve damage.
- B. Fluid overload leading to compression of nerve tissue.
- C. Sensation distortion due to psychiatric disturbance.
- D. Inflammation of the skin on the hands and feet.
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.