Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a surgical floor. Which information provided by the UAP requires immediate intervention by the nurse?
- A. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection.
- B. The client who has had a right upper lobectomy is complaining that the patient-controlled analgesia (PCA) pump is not providing any relief.
- C. The client diagnosed with cancer of the lung is complaining of being tired and short of breath.
- D. The client admitted with chronic obstructive pulmonary disease is making a whistling sound with every breath.
Correct Answer: A
Rationale: Bright-red drainage post-neck dissection (A) suggests hemorrhage, requiring immediate action. PCA failure (B), fatigue/SOB (C), and wheezing (D) are expected or less urgent.
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A patient received a nebulizer of Albuterol. What is a side effect of this medication?
- A. Bradycardia
- B. Tachycardia
- C. Drowsiness
- D. Feeling cold
Correct Answer: B
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to its stimulatory effects.
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply.
- A. Assess the client's level of consciousness.
- B. Monitor urine output every shift.
- C. Turn the client every two (2) hours.
- D. Maintain intravenous fluids as ordered.
- E. Place the client in the Fowler's position.
Correct Answer: A,C,D,E
Rationale: LOC assessment (A), turning (C), IV fluids (D), and Fowler’s position (E) support ARDS care. Urine output (B) should be monitored hourly, not per shift.
A patient with severe COPD is having an episode of extreme shortness of breath and requests their inhaler. Which type of inhaler ordered by the physician would provide the FASTEST relief for the patient based on this particular situation?
- A. Spiriva
- B. Salmeterol
- C. Symbicort
- D. Albuterol
Correct Answer: D
Rationale: Albuterol , a short-acting beta-agonist, provides rapid bronchodilation for acute shortness of breath. Spiriva , Salmeterol , and Symbicort are long-acting or combination drugs for maintenance.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.
Which statement by the client best indicates that the client understands the rationale for the direct laryngoscopy?
- A. The test will tell if my hoarseness is caused by tracheal polyps.
- B. The physician says that hoarseness can lead to bronchitis.
- C. I need to have the test because hoarseness is a symptom of laryngeal cancer.
- D. The physician wants to see if my hoarseness is because of enlarged tonsils.
Correct Answer: C
Rationale: Persistent hoarseness can be a symptom of laryngeal cancer, and direct laryngoscopy is used to visualize the larynx for abnormalities like tumors.