Nokea
A patient with emphysema may present with all of the following symptoms EXCEPT?
- A. Barrel chest
- B. Hyperinflation of the lungs
- C. Hypoventilation
- D. Hypercapnia
Correct Answer: C
Rationale: Emphysema causes barrel chest , lung hyperinflation , and often hypercapnia due to air trapping. Hypoventilation is not typical, as patients hyperventilate to compensate for poor gas exchange.
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The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?
- A. Notify the respiratory therapist immediately.
- B. Ventilate with a manual resuscitation bag.
- C. Request STAT arterial blood gases.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: Manual ventilation (B) ensures oxygenation during ventilator failure, a priority. Notification (A), ABGs (C), and auscultation (D) follow.
Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:
- A. Apply cool compresses to affected extremity
- B. Measure leg circumference
- C. Massage affected extremity
- D. Elevate affected extremity above heart level
- E. Encourage frequent ambulation
- F. Monitor the patient's INR level
- G. Monitor the patient's aPTT level
Correct Answer: B,D,G
Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.
Which nursing rationale best explains the reason for using a cuffed tracheostomy tube on the client?
- A. The cuff prevents skin breakdown.
- B. The cuff prevents aspiration.
- C. The cuff is more comfortable.
- D. The cuff reduces infection.
Correct Answer: B
Rationale: The cuff on a tracheostomy tube seals the airway, preventing aspiration of secretions or food into the lungs.
When caring for a client with a flail chest, which nursing action is most appropriate?
- A. Suction the client's airway.
- B. Tape the chest securely.
- C. Apply a chest binder.
- D. Encourage coughing.
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.
If the client is typical of most others diagnosed with lung cancer, which early-warning sign was most likely ignored?
- A. Difficulty swallowing
- B. Gradual weight loss
- C. Persistent cough
- D. Coughing up blood
Correct Answer: C
Rationale: A persistent cough is a common early symptom of lung cancer that is often ignored, delaying diagnosis.