Nokea
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.
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A patient with asthma is prescribed to take inhaled Salmeterol and Fluticasone for long-term management of asthma. You observe the patient taking these medications. Which option below best describes the correct order in how to take these medications?
- A. The patient inhales the Salmeterol first and then waits 5 minutes before inhaling the Fluticasone.
- B. The patient inhales the Fluticasone first and then waits 5 minutes before inhaling the Salmeterol.
- C. The patient inhales the Salmeterol first and then waits 1 minute before inhaling the Fluticasone.
- D. The patient inhales the Fluticasone and immediately inhales the Salmeterol.
Correct Answer: A
Rationale: Salmeterol, a long-acting bronchodilator, should be inhaled first to open the airways, followed by Fluticasone, a corticosteroid, after a 5-minute wait to ensure optimal delivery and reduce inflammation.
The client is admitted to emergency department complaining of shortness of breath and fever. The vital signs are T 100.4°F, P 94, R 26, and BP 134/86. Which concept should the nurse identify as a concern for the client? Select all that apply.
- A. Clotting.
- B. Oxygenation.
- C. Infection.
- D. Perfusion.
- E. Coping.
Correct Answer: B,C
Rationale: SOB and tachypnea (B) suggest oxygenation issues, and fever (C) indicates infection. Clotting (A), perfusion (D), and coping (E) are not primary based on data.
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.
Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
- A. I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks.
- B. I need to use my Intal, cromolyn inhaler, 15 minutes before I begin my exercise.
- C. I need to take oral glucocorticoids every day to prevent my asthma attacks.
- D. If I have an asthma attack, I need to use my albuterol, a beta2 agonist, inhaler.
Correct Answer: C
Rationale: Daily oral glucocorticoids (C) are not typically used for asthma maintenance due to significant side effects; they are reserved for severe exacerbations or specific cases. Inhaled corticosteroids or leukotriene modifiers (like Singulair, A) are preferred for long-term control. Using cromolyn before exercise (B) is correct to prevent exercise-induced bronchospasm. Albuterol for acute attacks (D) is appropriate as a rescue inhaler.