Nokea
The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time?
- A. Stimulate the client until the client responds.
- B. Increase the oxygen from the ordered 6 L to 10 L.
- C. Assess the client again in 15 minutes.
- D. Notify the charge nurse of the change in the client's mental status.
Correct Answer: D
Rationale: A change in mental status with worsening dyspnea indicates potential deterioration, requiring immediate notification of the charge nurse.
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The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?
- A. The client worked with asbestos for a short time many years ago.
- B. The client has no family history for this type of lung cancer.
- C. The client has numerous tattoos covering both upper and lower arms.
- D. The client has smoked two (2) packs of cigarettes a day for 20 years.
Correct Answer: D
Rationale: Smoking (D) (40 pack-years) is the primary risk factor for small cell lung cancer. Asbestos (A) is a risk but less significant, family history (B) is irrelevant, and tattoos (C) are unrelated.
The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client?
- A. Have you had the flu shot in the last two (2) weeks?
- B. Are there any small children in the home?
- C. Are you taking over-the-counter medicine for these symptoms?
- D. Do you have any cold sores associated with your sneezing?
Correct Answer: C
Rationale: Sneezing and nasal discharge suggest a URI; asking about OTC medications (C) assesses self-treatment and potential interactions. Flu shot timing (A) is irrelevant, children (B) are secondary, and cold sores (D) relate to herpes, not URI.
An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest x-ray. This indicated that at that time the client:
- A. was less susceptible to a tuberculosis infection than the year before.
- B. had acquired some degree of passive immunity to tuberculosis.
- C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis.
- D. had a mild tuberculosis infection in an organ other than the lung.
Correct Answer: C
Rationale: A positive PPD with a negative chest x-ray indicates exposure to Mycobacterium tuberculosis with an immune response but no active pulmonary disease.
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
- A. The client has an intake of 1,500 mL IV and an output of 1,000 mL.
- B. The client has 450 mL of bright-red drainage in the chest tube.
- C. The client is complaining of pain at a '10' on a 1-to-10 scale.
- D. The client has absent lung sounds on the side of the surgery.
Correct Answer: B
Rationale: 450 mL bright-red drainage (B) suggests hemorrhage, requiring immediate action. Fluid balance (A), severe pain (C), and absent lung sounds (D) are expected or less urgent.
You're assisting your patient who has asthma to bed. The patient is experiencing a frequent cough and chest tightness. You auscultate the patient's lung fields and note expiratory wheezes. The patient's peak flow rate is 78% less than their best peak flow reading. Which medication will provide the patient with the fastest relief from these signs and symptoms of an asthma attack?
- A. Theophylline
- B. Tiotropium
- C. Albuterol
- D. Cromolyn
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation, making it the fastest-acting medication for acute asthma symptoms.