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The client is admitted to emergency department complaining of shortness of breath and fever. The vital signs are T 100.4°F, P 94, R 26, and BP 134/86. Which concept should the nurse identify as a concern for the client? Select all that apply.
- A. Clotting.
- B. Oxygenation.
- C. Infection.
- D. Perfusion.
- E. Coping.
Correct Answer: B,C
Rationale: SOB and tachypnea (B) suggest oxygenation issues, and fever (C) indicates infection. Clotting (A), perfusion (D), and coping (E) are not primary based on data.
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The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.
While developing the postoperative care plan for the client, it is essential to have the client lie in which position?
- A. With the healthy lung uppermost
- B. With the head lower than the heart
- C. With the arms elevated on pillows
- D. On the operative side
Correct Answer: A
Rationale: Positioning with the healthy lung uppermost optimizes ventilation and perfusion in the remaining lung post-pneumonectomy.
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
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.
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 .