Nokea
The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?
- A. Myocardial infarction.
- B. Pneumonia.
- C. Pulmonary embolus.
- D. Pneumothorax.
Correct Answer: C
Rationale: Sudden chest pain and impending doom in a DVT patient suggest pulmonary embolus (C), where a clot dislodges to the lungs, causing acute respiratory distress. Myocardial infarction (A) presents with cardiac symptoms. Pneumonia (B) has gradual onset. Pneumothorax (D) causes unilateral symptoms.
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The nurse is planning the activities for the client diagnosed with asbestosis. Which activity should the nurse schedule at 0900 if breakfast is served at 0800?
- A. Assist with the client's bath and linen change.
- B. Administer an inhalation bronchodilator treatment.
- C. Provide the client with a one (1)-hour rest period.
- D. Have respiratory therapy perform chest physiotherapy.
Correct Answer: B
Rationale: Bronchodilator treatment (B) at 0900 optimizes lung function early in the day for asbestosis patients, who have restrictive lung disease. Bathing (A) is less urgent. A rest period (C) may be needed later, not immediately post-breakfast. Chest physiotherapy (D) is typically scheduled later to avoid postprandial discomfort.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
Which side effect can the nurse expect when the client receives aminophylline (Truphylline)?
- A. Bronchospasm
- B. Hypotension
- C. Drowsiness
- D. Tachycardia
Correct Answer: D
Rationale: Aminophylline, a xanthine derivative, commonly causes tachycardia as a side effect due to its stimulatory effects.
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.
The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which health-care provider order should the nurse implement first?
- A. Start IV with 1,000 mL 0.9% saline.
- B. Ceftriaxone 1 gm IVPB every 12 hours.
- C. Obtain sputum and blood cultures.
- D. CBC and basic metabolic panel.
Correct Answer: C
Rationale: Sputum/blood cultures (C) must be obtained before antibiotics to identify pathogens, a priority. IV fluids (A), antibiotics (B), and labs (D) follow.