Nokea
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.
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Until the client can be examined later that morning, which advice by the nurse would be most helpful?
- A. Sucking on ice chips should help.
- B. Rest your voice.
- C. Massage your throat.
Correct Answer: B
Rationale: Resting the voice reduces strain on the vocal cords, which is beneficial for laryngitis and helps prevent further irritation.
The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first?
- A. Milk the chest tube.
- B. Check the tubing for kinks.
- C. Instruct the client to cough.
- D. Assess the insertion site.
Correct Answer: B
Rationale: No tidaling in the water-seal compartment suggests a blockage or kink. Checking for kinks (B) is the first, non-invasive action to restore function. Milking (A) is avoided due to pressure risks. Coughing (C) is ineffective if tubing is blocked. Assessing the site (D) is secondary.
Which assessment technique is essential before allowing a client food or fluids after a bronchoscopy?
- A. Touch the arch of the palate with a tongue blade.
- B. Listen to the abdomen for active bowel sounds.
- C. Inspect the oral mucous membranes for integrity.
- D. Palpate the throat while the client swallows.
Correct Answer: D
Rationale: Palpating the throat while the client swallows confirms the gag reflex has returned, ensuring safe oral intake post-bronchoscopy.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.
You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education?
- A. Cough for a minimum of 6 weeks
- B. Night sweats
- C. Weight gain
- D. Hemoptysis
- E. Chills
- F. Fever
- G. Chest pain
Correct Answer: B,D,E,F,G
Rationale: Tuberculosis symptoms include night sweats , hemoptysis , chills , fever , and chest pain (G). A cough typically lasts 3 weeks or more, not necessarily 6 weeks (not A). Weight loss, not weight gain , is common.