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A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?
- A. Decreased chest expansion
- B. Cyanosis
- C. Pursed-lip breathing
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Pursed-lip breathing. In emphysema, air becomes trapped in the lungs due to damaged air sacs, making it difficult to exhale. Pursed-lip breathing helps to prolong exhalation, preventing air trapping. Decreased chest expansion (A) is more indicative of conditions like pleural effusion. Cyanosis (B) is a sign of inadequate oxygenation, which is not a primary manifestation of emphysema. Bradypnea (D) refers to slow breathing rate, which is not typically associated with emphysema. Pursed-lip breathing is a characteristic and effective coping mechanism seen in clients with emphysema.
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The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?
- A. Explain the importance of using the inhaler daily to prevent asthma attacks.
- B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
- C. Explore the client's fears regarding breathlessness.
- D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.
Correct Answer: B
Rationale: Step 1: The nurse must acknowledge the client's concern about the cost of the inhaler.
Step 2: Suggesting community services shows empathy and addresses the financial aspect.
Step 3: Encouraging daily use aligns with the standard treatment guidelines.
Step 4: By addressing both cost and importance of daily use, the nurse promotes adherence and support.
Summary of other choices:
A: Incorrect. This option doesn't address the client's financial concerns.
C: Incorrect. Focusing on fears of breathlessness doesn't directly address the client's cost concern.
D: Incorrect. While discussing daily use is important, not directly addressing the cost concern may lead to non-adherence.
Steps to prevent a pressure ulcer may include
- A. Not disturbing the patient.
- B. Changing the position of a bedbound patient every 4 hours.
- C. Vigorously rubbing the skin with alcohol.
- D. Avoiding pressure on the heels of a bedbound patient.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications.
A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease.
B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action.
C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.
How are pulse rate, volume, and rhythm used to identify the severity of shock and estimate the approximate reduction in blood volume?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
To clean a wound, it is best to use
- A. Hydrogen peroxide to bubble away the debris.
- B. Tap water.
- C. Saline.
- D. It is best not to disturb a healing wound.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.