Nokea
The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication?
- A. Muscle weakness.
- B. Purulent sputum.
- C. Nuchal rigidity.
- D. Intermittent loss of muscle control.
Correct Answer: C
Rationale: Nuchal rigidity (C) suggests meningitis, a life-threatening sinusitis complication. Muscle weakness (A) and loss of control (D) are unrelated, and purulent sputum (B) is more typical of respiratory infections.
You may also like to solve these questions
You are providing teaching to a patient with chronic COPD on how to perform diaphragmatic breathing. This technique helps do the following:
- A. Increase the breathing rate to prevent hypoxemia
- B. Decrease the use of the abdominal muscles
- C. Encourages the use of accessory muscles to help with breathing
- D. Strengthen the diaphragm
Correct Answer: D
Rationale: Diaphragmatic breathing strengthens the diaphragm , improving breathing efficiency in COPD. It doesn't increase breathing rate , decrease abdominal muscle use , or encourage accessory muscle use .
Which oxygen flow rate is most appropriate for the nurse to administer for this client?
- A. 2 L/minute
- B. 5 L/minute
- C. 8 L/minute
- D. 10 L/minute
Correct Answer: A
Rationale: A low flow rate of 2 L/minute is appropriate for COPD clients to avoid suppressing the hypoxic drive while improving oxygenation.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
The nurse instructs the client's spouse to empty and thoroughly clean the vaporizer after each use. Which rationale provides the basis for the nurse's instruction?
- A. There is a potential for injury if the vaporizer is accidentally knocked off a nightstand.
- B. When the vaporizer is not cleaned, there is the growth of environmental pathogens.
- C. The vaporizer can collect dust, which could affect the client's breathing.
- D. Water evaporation causes calcium deposits that will obstruct the vaporizer.
Correct Answer: B
Rationale: A cool-mist vaporizer can harbor pathogens like bacteria and mold if not cleaned properly, potentially worsening respiratory symptoms.
The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first?
- A. Notify the health-care provider to have chest tubes reinserted STAT.
- B. Instruct the client to take slow shallow breaths until the tube is reinserted.
- C. Take no action and assess the client's respiratory status every 15 minutes.
- D. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
Correct Answer: D
Rationale: An occlusive dressing taped on three sides (D) prevents air entry while allowing air exit, a priority. Notification (A), shallow breaths (B), and monitoring (C) follow.