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A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
- A. A 46-year-old with a 30-year history of smoking.
- B. A 52-year-old in a tripod position using accessory muscles to breathe.
- C. A 50-year-old with dependent edema and clubbed fingers.
- D. A 74-year-old with a chronic cough and thick, tenacious secretions.
Correct Answer: B
Rationale: A client in a tripod position using accessory muscles is in acute respiratory distress and requires immediate assessment to prevent respiratory failure. The other clients' symptoms, while concerning, do not indicate immediate distress.
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A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Strip the tubing to minimize clot formation and ensure patency.
- B. Secure tubing junctions with clamps to prevent accidental disconnections.
- C. Connect the chest tube to wall suction at the level prescribed by the provider.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct Answer: D
Rationale: Keeping padded clamps at the bedside ensures safety if the drainage system is interrupted. Stripping the tubing can cause harm, junctions should be taped not clamped, and suction levels are set per the device manufacturer, not the provider.
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for tracheal deviation.
- C. Perform peak expiratory flow readings.
- D. Administer prescribed albuterol (Proventil) inhaler.
- E. Encourage diaphragmatic breathing.
Correct Answer: C,D
Rationale: Suprasternal retraction and wheezing indicate acute asthma exacerbation. Administering albuterol (a short-acting beta2 agonist) is appropriate for immediate relief, and peak flow readings help assess severity. Salmeterol is a long-acting medication, not for acute attacks. Tracheal deviation is unrelated, and diaphragmatic breathing is not a priority during an acute attack.
The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. Press down firmly on the canister to release one dose of medication. 2. Breathe in slowly and deeply. 3. Shake the whole unit vigorously three or four times. 4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 5. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. 6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
- A. 2,3,5,1,6,2
- B. 3,4,5,1,2,6
- C. 4,3,5,1,2,6
- D. 1,3,2,5,6,7,4
Correct Answer: C
Rationale: The correct order is: insert the inhaler into the spacer (4), shake the unit (3), place the mouthpiece in the mouth (5), release the medication (1), breathe in slowly and deeply (2), and hold the breath for 10 seconds (6).
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Sudden onset of shortness of breath
- D. Pain at insertion site
- E. Drainage of 75 ml/hr
Correct Answer: C,E
Rationale: Sudden shortness of breath and tracheal deviation indicate a pneumothorax, requiring immediate intervention. Pink sputum, pain at the insertion site, and drainage of 75 ml/hr are not immediately life-threatening.
The nurse is caring for a client with lung cancer who states, 'I don't want any pain medication because I am afraid to become addicted.' How should the nurse respond?
- A. I will ask the provider to change your medication to a drug that is less potent.
- B. I will ask the provider to prescribe a non-opioid analgesic.
- C. It is unlikely you will become addicted when taking medicine for pain.
- D. I will discuss alternative pain relief methods like acupuncture.
Correct Answer: C
Rationale: The risk of addiction is low when pain medications are used appropriately for pain management in clients with cancer. Changing to a less potent drug or non-opioid may not adequately address pain. Alternative methods like acupuncture may be considered but are not the priority response.