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The nurse is assessing a patient who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
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The nurse is developing a teaching plan for a patient with a 12 pack-year history of cigarette smoking. Which of the following information should the nurse include in the plan of care?
- A. Computed tomography (CT) screening for lung cancer
- B. Options for smoking cessation
- C. Reasons for annual sputum cytology testing
- D. Erlotinib therapy to prevent tumour risk
Correct Answer: B
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumours.
Which of the following prescriptions should the nurse implement first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?
- A. Administer Aspirin suppository.
- B. Send to radiology for chest x-ray.
- C. Give ciprofloxacin 400 mg IV.
- D. Obtain blood cultures from two sites.
Correct Answer: D
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and Aspirin administration can be done last.
The nurse is conducting a chest assessment on a patient with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess?
- A. Vesicular breath sounds
- B. Increased tactile fremitus
- C. Dry, nonproductive cough
- D. Hyper-resonance to percussion
Correct Answer: B
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.
After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?
- A. A 7-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
- B. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
- C. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath
- D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 37.9 C (100.2 F)
Correct Answer: C
Rationale: Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The health care provider writes a prescription for bacteriological testing for a patient who has a positive tuberculosis skin test. Which of the following actions should the nurse take?
- A. Repeat the tuberculin skin testing.
- B. Teach about the reason for the blood tests.
- C. Obtain consecutive sputum specimens from the patient for 3 days.
- D. Instruct the patient to expectorate three specimens as soon as possible.
Correct Answer: C
Rationale: Three consecutive sputum specimens are obtained on different days for bacteriological testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.