Nokea
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?
- A. Notify the respiratory therapist immediately.
- B. Ventilate with a manual resuscitation bag.
- C. Request STAT arterial blood gases.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: Manual ventilation (B) ensures oxygenation during ventilator failure, a priority. Notification (A), ABGs (C), and auscultation (D) follow.
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A patient with emphysema may present with all of the following symptoms EXCEPT?
- A. Barrel chest
- B. Hyperinflation of the lungs
- C. Hypoventilation
- D. Hypercapnia
Correct Answer: C
Rationale: Emphysema causes barrel chest , lung hyperinflation , and often hypercapnia due to air trapping. Hypoventilation is not typical, as patients hyperventilate to compensate for poor gas exchange.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
- A. Administer the ordered oral antibiotic immediately (STAT).
- B. Order the meal tray to be delivered as soon as possible.
- C. Obtain a sputum specimen for culture and sensitivity.
- D. Have the unlicensed assistive personnel weigh the client.
Correct Answer: C
Rationale: Obtaining sputum culture (C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (A) follow, meals (B) and weight (D) are less urgent.
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
- A. The most difficult time of the day for me is the first hour after waking up in the morning.'
- B. I feel best in the morning after a good night's sleep.'
- C. I seem to have more energy after eating a big meal.'
- D. I don't know why, but I get my 'second wind' at night and don't want to go to bed.'
Correct Answer: A
Rationale: Morning fatigue is common in COPD due to mucus accumulation and poor sleep, affecting activity tolerance.
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.