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After using a nasal cannula delivery system at 3 L/min, a patient with chronic airflow
limitation (CAL) changes to a simple face mask. The nasal equipment oxygen was set at 3
L/min. How should the nurse adjust the oxygen flow for the new delivery system?
- A. Decrease it to 2 L.
- B. Keep it the same.
- C. Increase it to 4 L.
- D. Increase it to 6 L.
Correct Answer: D
Rationale: To determine the correct oxygen flow for a simple face mask, you should increase it from the previous nasal cannula rate. As simple face masks deliver oxygen less efficiently, a higher flow rate is needed to maintain the same oxygen concentration. Moving from 3 L/min nasal cannula to a simple face mask, you should increase the flow to 6 L/min to ensure adequate oxygen delivery to the patient with chronic airflow limitation. Choices A and B are incorrect as decreasing or keeping the flow the same would not provide sufficient oxygen. Choice C is also incorrect as increasing it to 4 L/min may not be enough to compensate for the decreased efficiency of the simple face mask.
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A client seen in the emergency department reports fever,fatigue and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?
- A. Collect a sputum sample for culture by deep suctioning.
- B. Inform the client that oral antibiotics will be needed for 60 days.
- C. Place the client on Airborne Precautions immediately.
- D. Tell the client that directly observed therapy is needed.
Correct Answer: B
Rationale: The correct answer is B: Inform the client that oral antibiotics will be needed for 60 days. This is the best action because the client is showing symptoms consistent with tuberculosis, such as fever, fatigue, dry cough, and mediastinal widening on chest x-ray. Treatment for tuberculosis typically involves a combination of oral antibiotics for a prolonged period, usually 6-9 months. Collecting a sputum sample for culture by deep suctioning (A) may be necessary to confirm the diagnosis but is not the priority at this moment. Placing the client on Airborne Precautions immediately (C) is important once the diagnosis is confirmed, not the initial action. Directly observed therapy (D) is a method to ensure adherence to medication but is not the immediate next step.
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patient's physician because these symptoms are suggestive of what?
- A. Pneumothorax
- B. Lung tumors
- C. Infection
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Infection. The greenish color and large quantity of sputum suggest an infection in the lungs, typically caused by bacteria. Greenish sputum is often a sign of bacterial pneumonia. Fever and cough are common symptoms of a lung infection, along with increased sputum production. Pneumothorax (A) is characterized by a collapsed lung and does not typically present with greenish sputum. Lung tumors (B) may cause cough and sputum production, but the color of the sputum is not specific to tumors. Pulmonary edema (D) is a condition where fluid accumulates in the lungs, leading to shortness of breath and pink, frothy sputum, not greenish sputum.
The nurse is preparing the patient for and will assist the physician with a thoracentesis in the patient’s room. Number the following actions in the order the nurse should complete them.
- A. Verify breath sounds in all fields.
- B. Obtain the supplies that will be used.
- C. Send labeled specimen containers to the lab.
- D. Direct the family members to the waiting room.
Correct Answer: B
Rationale: The nurse should first obtain the supplies that will be used to ensure that everything needed for the thoracentesis procedure is readily available. This step is crucial for the successful completion of the procedure and the safety of the patient.
Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to?
- A. Promote expectoration.
- B. Suppress the cough.
- C. Relax smooth muscles of the bronchial airway.
- D. Prevent infection.
Correct Answer: C
Rationale: The correct answer is C: Relax smooth muscles of the bronchial airway. Aminophylline (theophylline) is a bronchodilator that works by relaxing the smooth muscles in the bronchial airways, which helps to open up the airways and improve airflow. This action helps to relieve bronchospasm, which is common in conditions like acute bronchitis. Promoting expectoration (A) and suppressing cough (B) are not the primary actions of aminophylline, although they may be secondary effects. Preventing infection (D) is unrelated to the mechanism of action of aminophylline in treating acute bronchitis.
A patient on the medical unit has told the nurse that he is experiencing significant
dyspnea, despite that he has not recently performed any physical activity. What
assessment question should the nurse ask the patient while preparing to perform a
physical assessment?
- A. On a scale from 1 to 10, how bad would rate your shortness of breath?
- B. When was the last time you ate or drank anything?
- C. Are you feeling any nausea along with your shortness of breath?
- D. Do you think that some medication might help you catch your breath?
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
1. Assessing the severity of dyspnea is crucial for determining the urgency of intervention.
2. By asking for a rating on a scale from 1 to 10, the nurse can quantify the level of distress the patient is experiencing.
3. This allows for a more objective assessment and helps in determining appropriate interventions.
4. Monitoring changes in the severity of dyspnea over time can also guide treatment effectiveness.
Summary of Incorrect Choices:
B. Asking about the last time the patient ate or drank is important for assessing possible contributing factors to dyspnea, but it does not directly address the immediate severity of the symptom.
C. Inquiring about nausea is relevant for a more comprehensive assessment, but it does not directly address the severity of dyspnea.
D. Asking about the potential need for medication is important, but it does not directly address the current level of dyspnea and may not be the immediate priority.