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The nurse is caring for a patient immediately postoperative after a left pneumonectomy. How should the nurse position the patient?
- A. In high Fowler position
- B. In semi-Fowler position
- C. In a right side-lying position
- D. In a left side-lying position
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Post-pneumonectomy, positioning the patient on the left side allows the remaining lung to expand fully.
2. This position promotes better ventilation and perfusion, aiding in oxygenation.
3. Placing the patient on the left side also helps prevent pressure on the surgical site.
4. The left side-lying position also facilitates drainage and prevents pooling of secretions in the surgical area.
Summary of why other choices are incorrect:
A. High Fowler position may cause increased pressure on the surgical site and impede lung expansion.
B. Semi-Fowler position may not optimize lung expansion and could lead to decreased oxygenation.
C. Right side-lying position is not ideal as it does not facilitate full expansion of the remaining lung and may cause pooling of secretions.
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Delegation Decision: The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?
- A. Assist the patient to get out of bed.
- B. Auscultate breath sounds every 4 hours.
- C. Plan patient activities to minimize exertion.
- D. Teach the patient pursed lip breathing technique.
Correct Answer: A
Rationale: Assisting the patient to get out of bed can be safely delegated to unlicensed assistive personnel (UAP) as it does not require specialized nursing knowledge or skills. It is a basic activity of daily living that can be delegated to support staff while allowing nurses to focus on more complex patient care tasks.
A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next?
- A. Assess the client for obstructive sleep apnea.
- B. Arrange a home sleep apnea test.
- C. Encourage the client to begin exercising.
- D. Schedule a polysomnography
Correct Answer: A
Rationale: The correct answer is A: Assess the client for obstructive sleep apnea. Hypertension that is not responding to medications may be due to underlying sleep apnea, a common comorbidity. By assessing for obstructive sleep apnea, the nurse can identify a potential contributing factor to the client's uncontrolled hypertension. This step is crucial in managing the client's condition effectively.
Summary of other choices:
B: Arranging a home sleep apnea test may be premature without first assessing the client for obstructive sleep apnea.
C: Encouraging the client to begin exercising is important for overall health but may not directly address the uncontrolled hypertension.
D: Scheduling a polysomnography may be necessary if obstructive sleep apnea is suspected after the initial assessment.
A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if a health concern occurs?
- A. Impaired color discrimination
- B. Increased urinary frequency
- C. Decreased hearing acuity
- D. Increased appetite
Correct Answer: C
Rationale: The correct answer is C: Decreased hearing acuity. Streptomycin is known to cause ototoxicity, which can lead to decreased hearing acuity. Therefore, the nurse should instruct the client to notify the physician if any changes in hearing occur to prevent permanent hearing loss. Impaired color discrimination (A) and increased appetite (D) are not commonly associated with streptomycin use. Increased urinary frequency (B) is not a typical side effect of streptomycin and would not require immediate physician notification.
The nurse has assessed a patient's family history for three generations. The presence of
which respiratory disease would justify this type of assessment?
- A. Asthma
- B. Obstructive sleep apnea
- C. Community-acquired pneumonia
- D. Pulmonary edema
Correct Answer: A
Rationale: Step-by-step rationale:
1. Asthma is a hereditary respiratory disease, making it important to assess family history.
2. Genetic predisposition plays a role in the development of asthma.
3. Understanding family history helps in identifying potential risk factors.
4. Obstructive sleep apnea, community-acquired pneumonia, and pulmonary edema are not typically hereditary respiratory diseases.
5. Therefore, assessing family history for three generations is justified for asthma.
Stimulation of the apneustic center would result in
- A. increased respiratory rate
- B. more intense inhalation
- C. a shorter respiratory cycle
- D. less activity in the DRG center
Correct Answer: B
Rationale: The correct answer is B: more intense inhalation. The apneustic center is responsible for prolonging inhalation by stimulating the inspiratory neurons in the medulla oblongata. When the apneustic center is stimulated, it disrupts the normal breathing pattern, causing a prolonged and more intense inhalation. This results in deeper and more forceful breaths.
Incorrect choices:
A: increased respiratory rate - Stimulation of the apneustic center would not lead to an increased respiratory rate, but rather to changes in the depth and intensity of inhalation.
C: a shorter respiratory cycle - The apneustic center's stimulation does not lead to a shorter respiratory cycle, but rather to a prolonged inhalation phase.
D: less activity in the DRG center - The dorsal respiratory group (DRG) is responsible for initiating inspiration, and the apneustic center does not affect its activity.