Nokea
An adult is to have a tracheostomy performed. What is the nursing priority?
- A. Shave the neck
- B. Establish a means of communication
- C. Insert a Foley catheter
- D. Start an IV
Correct Answer: B
Rationale: Establishing a means of communication is the priority, as the client will lose the ability to speak post-tracheostomy.
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You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
- A. Easily fatigued with physical activity
- B. Reduced peak flow meter reading
- C. Chest retractions
- D. Cyanosis
- E. Wheezing with activity
- F. Nighttime coughing
- G. No relief with short-acting bronchodilator inhaler
Correct Answer: A,B,E,F
Rationale: Early warning signs include fatigue, reduced peak flow, wheezing with activity, and nighttime coughing. Chest retractions, cyanosis, and no relief from a bronchodilator indicate a more severe attack.
The client admitted for recurrent aspiration pneumonia is at risk for bronchiectasis. Which intervention should the nurse anticipate the health-care provider to order?
- A. Administer intravenous antibiotics for seven (7) days.
- B. Insert a subclavian line and initiate total parenteral nutrition.
- C. Provide a low-calorie and low-sodium restricted diet.
- D. Encourage the client to turn, cough, and deep breathe frequently.
Correct Answer: D
Rationale: Recurrent aspiration pneumonia predisposes to bronchiectasis due to chronic airway damage. Turning, coughing, and deep breathing (D) prevent secretion stasis and further infections. Antibiotics (A) treat active infection, not prevention. TPN (B) is for malnutrition, not directly related. Dietary restrictions (C) are irrelevant.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
- A. Assess the client for abnormal bleeding.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Administer the medication as ordered.
- D. Notify the HCP to obtain an order to increase the dose.
Correct Answer: C
Rationale: INR 2.8 (C) is therapeutic for PE (2–3), so administer warfarin. Bleeding assessment (A) is routine, vitamin K (B) reverses overdose, and increasing dose (D) is unnecessary.
For the client who has just had a pneumonectomy, what is a temporary, expected outcome of thoracic surgery?
- A. The client's ability to speak
- B. Chest numbness
- C. Impaired swallowing
- D. Sore throat
Correct Answer: B
Rationale: Chest numbness is an expected temporary outcome due to nerve disruption during thoracic surgery.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.