Nokea
The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
- A. Bronchovesicular lung sounds and bradypnea.
- B. Unequal lung expansion and dyspnea.
- C. Frothy, bloody sputum and consolidation.
- D. Barrel chest and polycythemia.
Correct Answer: B
Rationale: Pneumothorax causes unequal lung expansion and dyspnea (B) from collapsed lung. Bronchovesicular sounds/bradypnea (A), frothy sputum (C), and barrel chest (D) suggest other conditions.
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Which referral is most appropriate for a client diagnosed with end-stage COPD?
- A. The Asthma Foundation of America.
- B. The American Cancer Society.
- C. The American Lung Association.
- D. The American Heart Association.
Correct Answer: C
Rationale: The American Lung Association (C) supports COPD patients with resources. Asthma Foundation (A), Cancer Society (B), and Heart Association (D) are less relevant.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
- A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
- B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
- C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
- D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
When caring for a client with a flail chest, which nursing action is most appropriate?
- A. Suction the client's airway.
- B. Tape the chest securely.
- C. Apply a chest binder.
- D. Encourage coughing.
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.