Nokea
A patient with newly diagnosed lung cancer tells the nurse, 'I think I am going to die pretty soon.' Which of the following responses 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.
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After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?
- A. A 7-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
- B. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
- C. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath
- D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 37.9 C (100.2 F)
Correct Answer: C
Rationale: Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The nurse is assessing a patient who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
The nurse is caring for a patient who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
- A. Document the presence of a large air leak.
- B. Obtain and attach a new collection device.
- C. Notify the surgeon of a possible pneumothorax.
- D. Take no further action with the collection device.
Correct Answer: D
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
The nurse is caring for a patient with right lower-lobe pneumonia who has been treated with intravenous (IV) antibiotics for 2 days. Which of the following assessment data obtained by the nurse indicates that the treatment has been effective?
- A. Bronchial breath sounds are heard at the right base.
- B. The patient coughs up small amounts of green mucus.
- C. The patient's white blood cell (WBC) count is 9 x 10^9/L.
- D. Increased tactile fremitus is palpable over the right chest.
Correct Answer: C
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
The nurse is providing teaching to a patient with pneumonia. Which of the following patient statements indicate a good understanding of the discharge instructions given by the nurse?
- A. I will call the doctor if I still feel tired after a week.
- B. I will need to use home oxygen therapy for 3 months.
- C. I will continue to do the deep-breathing and coughing exercises at home.
- D. I will schedule two appointments for the pneumonia and influenza vaccines.
Correct Answer: C
Rationale: Patients should continue to cough and deep breathe after discharge for up to 6-8 weeks. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumonia and influenza vaccines can be given at the same time.