Nokea
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.
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The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
What nursing action is most appropriate when administering both types of oral medication to this client?
- A. Administer the cough syrup first, then the tablets.
- B. Wait 15 minutes after giving the cough syrup before giving the tablets.
- C. Give the cough syrup between administering the tablets.
- D. Administer the tablets first, then the cough syrup.
Correct Answer: D
Rationale: Administering tablets first ensures they are swallowed properly, followed by the cough syrup, which may coat the throat and aid swallowing.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.
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.
A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect?
- A. Penicillin
- B. Fluroquinolones
- C. Tetracyclines
- D. Macrolides
Correct Answer: B
Rationale: Fluoroquinolones are associated with tendon rupture, including Achilles tendon, as a rare but serious side effect. Other antibiotics listed (A, C, D) are not commonly linked to this adverse effect.