Nokea
The best evidence that the client understands the procedure for a pulmonary function test is when stating that it involves which action?
- A. Having an X-ray taken
- B. Drawing a blood specimen
- C. Breathing into a mouthpiece
- D. Examining expectorated sputum
Correct Answer: C
Rationale: Pulmonary function tests involve breathing into a mouthpiece to measure lung capacity and airflow.
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The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
How should the nurse position the client while undergoing a thoracentesis?
- A. Lithotomy position
- B. Sitting
- C. Prone
- D. Supine
Correct Answer: B
Rationale: Sitting upright with arms supported allows access to the pleural space and minimizes complications during thoracentesis.
When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing?
- A. The client's first skin test indicates a purple flat area at the site of injection.
- B. The client's second skin test indicates a red area measuring four (4) mm.
- C. The client's previous skin test was read as positive.
- D. The client has never shown a reaction to the tuberculin medication.
Correct Answer: C
Rationale: A prior positive TB skin test (C) indicates exposure, requiring CXR to assess active disease, not repeat skin testing. Purple area (A) is normal, 4 mm (B) is negative, and no reaction (D) warrants testing.
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 ' $F$. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia?
- A. Aspiration pneumonia
- B. Ventilator acquired pneumonia
- C. Hospital-acquired pneumonia
- D. Community-acquired pneumonia
Correct Answer: C
Rationale: Hospital-acquired pneumonia (HAP) develops 48 hours or more after hospital admission, as seen in this patient. Aspiration pneumonia is linked to inhaling foreign material, ventilator-acquired pneumonia requires mechanical ventilation, and community-acquired pneumonia occurs outside healthcare settings.