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The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?
- A. Check the tubing for any kinks.
- B. Suction the airway for secretions.
- C. Assess the lip line of the ET tube.
- D. Sedate the client with a muscle relaxant.
Correct Answer: A
Rationale: High airway pressure may result from kinks (A), a common cause requiring immediate check. Suctioning (B), lip line (C), and sedation (D) follow if needed.
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The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.
- A. The client will be able to speak again after the surgery area has healed.
- B. The client should wear a protective covering over the stoma when showering.
- C. The client should clean the stoma and then apply a petroleum-based ointment.
- D. The client should use a humidifier in the room.
- E. The client can get a special telephone for communication.
Correct Answer: B,D,E
Rationale: Showering protection (B), humidifiers (D), and special phones (E) support tracheostomy care. Speech (A) is lost permanently, and petroleum ointment (C) risks infection.
An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. He is also receiving pyridoxine (vitamin B6). Why is this medication prescribed for him?
- A. Pyridoxine is bacteriostatic against Mycobacterium tuberculosis.
- B. To enhance his general nutritional status
- C. To prevent side effects of INH
- D. Pyridoxine acts to increase the effects of streptomycin.
Correct Answer: C
Rationale: Pyridoxine is prescribed to prevent INH-induced peripheral neuritis by supporting nerve function.
Which datum requires immediate intervention by the nurse for the client diagnosed with asbestosis?
- A. The client develops an S3 heart sound.
- B. The client has clubbing of the fingers.
- C. The client is fatigued in the afternoon.
- D. The client has basilar crackles in all lobes.
Correct Answer: A
Rationale: An S3 heart sound (A) indicates heart failure, a serious complication in asbestosis due to pulmonary hypertension, requiring immediate intervention. Clubbing (B) is a chronic finding, not acute. Fatigue (C) is common but not urgent. Basilar crackles (D) are expected in asbestosis and less critical than cardiac issues.
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
- A. Keep head-of-the-bed less than 30 degrees at all times.
- B. Collect sputum cultures.
- C. Encourage 3L of fluids a day to keep secretions thin.
- D. Encourage incentive spirometer usage
- E. Provide education about receiving the Pneumovax vaccine annually.
Correct Answer: B,D
Rationale: Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.
Because of this client's impaired speech, which nursing action facilitates communication?
- A. Discourage the client's attempts at communication.
- B. Inform the client to speak slowly when talking.
- C. Listen attentively to the client's vocalizations.
- D. Provide the client with paper and pencil.
Correct Answer: D
Rationale: Providing paper and pencil allows the client with impaired speech post-laryngectomy to communicate effectively through writing.