Nokea
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
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The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
Which question is most important for the nurse to ask the client at this time?
- A. When did you last take your prescribed medications?
- B. Have you taken all your medications as prescribed?
- C. How many drug refills have you obtained?
- D. Have you experienced any drug side effects?
Correct Answer: B
Rationale: Asking if the client has taken all medications as prescribed assesses adherence, which is critical for tuberculosis treatment efficacy.
Which statement is correct regarding mycobacterium tuberculosis?
- A. This bacterium is an anaerobic type of bacteria.
- B. It is an alkali bacterium that stains bright red during an acidfast smear test.
- C. It is known as being an aerobic type of bacteria.
- D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.
Correct Answer: C
Rationale: Mycobacterium tuberculosis is an aerobic bacterium. It is acid-fast and stains red (not green) during an acid-fast smear due to its mycolic acid-rich cell wall. It is not anaerobic or alkali.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.
Which discharge instruction is most appropriate for reducing the client's fatigue and shortness of breath during mealtimes?
- A. Eat simple carbohydrates for quick energy.
- B. Eat fatty foods to get maximum caloric intake.
- C. Eat frequent, small meals to reduce energy use.
- D. Eat the largest meal late at night before sleep.
Correct Answer: C
Rationale: Frequent, small meals reduce the energy required for digestion, minimizing fatigue and shortness of breath in COPD clients.