Nokea
The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?
- A. Administer the narcotic analgesic intravenous push (IVP).
- B. Perform gentle oral hygiene.
- C. Place the client in semi-Fowler's position.
- D. Assess the client's pain.
Correct Answer: D
Rationale: Pain assessment (D) is the first step to determine severity and guide treatment. Narcotics (A), oral hygiene (B), and positioning (C) follow based on assessment.
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A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
An alarm beeps notifying you that one of your patient's oxygen saturation is reading $89 \%$. You arrive to the patient's room, and see the patient comfortably resting in bed watching television. The patient is already on $2 \mathrm{~L}$ of oxygen via nasal cannula. The patient is admitted for COPD exacerbation. Your next nursing action would be:
- A. Continue to monitor the patient
- B. Increase the patient's oxygen level to $3 \mathrm{~L}$
- C. Notify the doctor for further orders
- D. Turn off the alarm settings
Correct Answer: A
Rationale: In COPD, oxygen saturation of 88-92% is acceptable to avoid suppressing the hypoxic drive. Since the patient is comfortable, continue monitoring . Increasing oxygen or notifying the doctor is unnecessary unless symptoms worsen.
An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?
- A. Reddish-orange color of urine, sputum, and saliva
- B. Erythema and urticaria
- C. Tinnitus and deafness
- D. Peripheral neuritis
Correct Answer: A
Rationale: Rifampin commonly causes a harmless reddish-orange discoloration of body fluids.
The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response?
- A. Close the door and discuss the UAP's action after coming out of the room.
- B. Make the UAP come back outside the room and then reenter, closing the door.
- C. Say nothing to the UAP but report the incident to the nursing supervisor.
- D. Enter the client's room and discuss the matter with the UAP immediately.
Correct Answer: A
Rationale: Closing the door (A) maintains airborne precautions, and discussing later ensures education without disrupting care. Reentering (B) is unnecessary, reporting (C) escalates prematurely, and discussing inside (D) risks exposure.
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.