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The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach?
- A. Demonstrate the proper method of gargling with normal saline.
- B. Perform voice exercises for 30 minutes three (3) times a day.
- C. Explain that a lighted instrument will be placed in the throat to biopsy the area.
- D. Teach the client to self-examine the larynx monthly.
Correct Answer: C
Rationale: Laryngoscopy with biopsy (C) diagnoses laryngeal cancer, requiring client education. Gargling (A), voice exercises (B), and self-examination (D) are not diagnostic.
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The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
- A. Demonstrate the correct technique for giving a bed bath.
- B. Encourage the UAP to put the bed in the lowest position.
- C. Instruct the UAP to get another person to help with the bath.
- D. Provide praise for performing the bath safely for the client and the UAP.
Correct Answer: B
Rationale: Lowering the bed (B) prevents falls, critical for ARDS patients. Demonstration (A), extra help (C), and praise (D) are inappropriate given safety concerns.
Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.
The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions?
- A. I will call 911 if my medications don't control an attack.
- B. I will wash my bedding in warm water.
- C. I can still eat at the Chinese restaurant when I want.
- D. If I get a headache, I should take a nonsteroidal anti-inflammatory drug.
Correct Answer: A
Rationale: Calling 911 for uncontrolled asthma (A) shows understanding of emergency action. Warm water (B) is insufficient (hot water needed), Chinese food (C) may contain MSG, and NSAIDs (D) can trigger asthma.
The nurse instructs the client's spouse to empty and thoroughly clean the vaporizer after each use. Which rationale provides the basis for the nurse's instruction?
- A. There is a potential for injury if the vaporizer is accidentally knocked off a nightstand.
- B. When the vaporizer is not cleaned, there is the growth of environmental pathogens.
- C. The vaporizer can collect dust, which could affect the client's breathing.
- D. Water evaporation causes calcium deposits that will obstruct the vaporizer.
Correct Answer: B
Rationale: A cool-mist vaporizer can harbor pathogens like bacteria and mold if not cleaned properly, potentially worsening respiratory symptoms.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.