Nokea
The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?
- A. Administer intravenous fluids of normal saline at 125 mL/hr.
- B. Provide supplemental oxygen per nasal cannula at 2 L/min.
- C. Continuous telemetry monitoring with strips every four (4) hours.
- D. Administer a loop diuretic intravenously every six (6) hours.
Correct Answer: A
Rationale: A mean pulmonary artery pressure of 35 mm Hg indicates pulmonary hypertension, common in end-stage COPD. IV fluids at 125 mL/hr (A) risk fluid overload and worsening right heart strain, so this order should be questioned. Oxygen (B), telemetry (C), and diuretics (D) are appropriate to manage hypoxia, monitor cardiac status, and reduce fluid overload.
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You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
- A. Easily fatigued with physical activity
- B. Reduced peak flow meter reading
- C. Chest retractions
- D. Cyanosis
- E. Wheezing with activity
- F. Nighttime coughing
- G. No relief with short-acting bronchodilator inhaler
Correct Answer: A,B,E,F
Rationale: Early warning signs include fatigue, reduced peak flow, wheezing with activity, and nighttime coughing. Chest retractions, cyanosis, and no relief from a bronchodilator indicate a more severe attack.
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
- A. The client has an intake of 1,500 mL IV and an output of 1,000 mL.
- B. The client has 450 mL of bright-red drainage in the chest tube.
- C. The client is complaining of pain at a '10' on a 1-to-10 scale.
- D. The client has absent lung sounds on the side of the surgery.
Correct Answer: B
Rationale: 450 mL bright-red drainage (B) suggests hemorrhage, requiring immediate action. Fluid balance (A), severe pain (C), and absent lung sounds (D) are expected or less urgent.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.
The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?
- A. The client worked with asbestos for a short time many years ago.
- B. The client has no family history for this type of lung cancer.
- C. The client has numerous tattoos covering both upper and lower arms.
- D. The client has smoked two (2) packs of cigarettes a day for 20 years.
Correct Answer: D
Rationale: Smoking (D) (40 pack-years) is the primary risk factor for small cell lung cancer. Asbestos (A) is a risk but less significant, family history (B) is irrelevant, and tattoos (C) are unrelated.
Which question is essential for the nurse to ask before administering the influenza vaccine?
- A. Have you had influenza in the last year?
- B. Did you receive pneumonia vaccine last year?
- C. Are you allergic to eggs or egg products?
- D. Do you have a history of respiratory disease?
Correct Answer: C
Rationale: Influenza vaccines are often produced using eggs, so an egg allergy must be assessed to prevent allergic reactions.