Nokea
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
- A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
- B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
- C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
- D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.
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You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education?
- A. Cough for a minimum of 6 weeks
- B. Night sweats
- C. Weight gain
- D. Hemoptysis
- E. Chills
- F. Fever
- G. Chest pain
Correct Answer: B,D,E,F,G
Rationale: Tuberculosis symptoms include night sweats , hemoptysis , chills , fever , and chest pain (G). A cough typically lasts 3 weeks or more, not necessarily 6 weeks (not A). Weight loss, not weight gain , is common.
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: Rifampin commonly causes orange discoloration of body fluids (sweat, urine, tears) as a harmless side effect, and patients should be educated to expect this.
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.
If the client is typical of most others diagnosed with lung cancer, which early-warning sign was most likely ignored?
- A. Difficulty swallowing
- B. Gradual weight loss
- C. Persistent cough
- D. Coughing up blood
Correct Answer: C
Rationale: A persistent cough is a common early symptom of lung cancer that is often ignored, delaying diagnosis.
Which assessment technique is essential before allowing a client food or fluids after a bronchoscopy?
- A. Touch the arch of the palate with a tongue blade.
- B. Listen to the abdomen for active bowel sounds.
- C. Inspect the oral mucous membranes for integrity.
- D. Palpate the throat while the client swallows.
Correct Answer: D
Rationale: Palpating the throat while the client swallows confirms the gag reflex has returned, ensuring safe oral intake post-bronchoscopy.