Nokea
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
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The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
Which is the correct volume needed for the nurse to administer the prescribed dose of 0.1 mg of epinephrine to the client?
- A. 0.001 mL
- B. 0.1 mL
- C. 1.0 mL
- D. 10 mL
Correct Answer: B
Rationale: For a 1:1,000 epinephrine solution (1 mg/mL), a 0.1 mg dose equals 0.1 mL, calculated as 0.1 mg ÷ 1 mg/mL = 0.1 mL.
When the nurse obtains the nasal swab, which action is most accurate?
- A. The nurse dons sterile gloves before obtaining the specimen.
- B. The swab is placed in the anterior portion of the nare and swept superiorly.
- C. The client is asked to blow the nose before the specimen is collected.
- D. The nurse uses separate applicators for each nare.
Correct Answer: D
Rationale: Using separate applicators for each nare prevents cross-contamination and ensures an accurate sample for MRSA screening.
A patient is ordered by the physician to take Pulmicort and Spiriva via inhaler. How should the patient take this medication?
- A. The patient should use the medications every 2 hours for acute episodes of shortness of breath.
- B. The patient should use the Spiriva first and then 5 minutes later the Pulmicort.
- C. The patient should use the Pulmicort first and then the Spiriva 5 minutes later.
- D. The patient should use the medications at the same exact time, regardless of the order.
Correct Answer: B
Rationale: Spiriva (anticholinergic) should be used first to open airways, followed by Pulmicort (corticosteroid) 5 minutes later to reduce inflammation. Every 2 hours is incorrect for maintenance drugs, and order matters (C, D).
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.