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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Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
- A. Vitamin C, 2,000 mg daily.
- B. Strict bedrest.
- C. Humidification of the air.
- D. Decongestant therapy.
Correct Answer: A
Rationale: Vitamin C (A) is an alternative therapy for colds, with unproven efficacy. Bedrest (B), humidification (C), and decongestants (D) are standard supportive measures.
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
Which outcome is appropriate for the client problem 'ineffective gas exchange' for the client recently diagnosed with COPD?
- A. The client demonstrates the correct way to pursed-lip breathe.
- B. The client lists three (3) signs/symptoms to report to the HCP.
- C. The client will drink at least 2,500 mL of water daily.
- D. The client will be able to ambulate 100 feet with dyspnea.
Correct Answer: A
Rationale: Pursed-lip breathing (A) improves gas exchange by prolonging exhalation. Symptom reporting (B), hydration (C), and ambulation with dyspnea (D) are unrelated to gas exchange.
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.