Nokea
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.
- A. Place the client on oxygen delivered by nasal cannula.
- B. Plan for periods of rest during activities of daily living.
- C. Place the client on a fluid restriction of 1,000 mL/day.
- D. Restrict the client's smoking to two (2) to three (3) cigarettes per day.
- E. Monitor the client's pulse oximetry readings every four (4) hours.
Correct Answer: B,E
Rationale: Rest periods (B) conserve energy, and pulse oximetry (E) monitors oxygenation in pneumonia. Oxygen (A) depends on SpO2, fluid restriction (C) is inappropriate, and smoking (D) must stop.
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The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma in clients diagnosed with chronic obstructive pulmonary disease (COPD)?
- A. A bronchoscopy.
- B. An immunoglobulin E.
- C. An arterial blood gas.
- D. A bronchodilator reversibility test.
Correct Answer: D
Rationale: A bronchodilator reversibility test differentiates asthma from COPD by assessing whether airway obstruction is reversible. In asthma, lung function (e.g., FEV1) improves significantly post-bronchodilator, while COPD shows minimal improvement. Bronchoscopy (A) is invasive and not specific for this differentiation. Immunoglobulin E (B) is relevant for allergies, not distinguishing asthma from COPD. Arterial blood gases (C) assess oxygenation but do not differentiate these conditions.
A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD result does NOT necessarily mean the patient has an active infection of TB. The patient will need a chest x-ray and sputum culture to determine if mycobacterium tuberculosis is present and then treatment will be based on those results. The IGRA test does NOT differentiate between LTBI or an active TB infection. Patients are placed in airborne precautions (NOT droplet) if they have ACTIVE TB.
Before recommending the use of a nonprescription decongestant to a client with a cold, which aspect of the medical history should be assessed? Select all that apply.
- A. Arthritis
- B. Asthma
- C. Hypertension
- D. Diabetes
- E. Glaucoma
- F. Arrhythmias
Correct Answer: C, E, F
Rationale: Decongestants can exacerbate hypertension, glaucoma, and arrhythmias due to their vasoconstrictive effects. Asthma is also a concern as decongestants may worsen respiratory symptoms in some cases.
Based on the client's clinical presentation, which drug should the nurse anticipate will be administered intravenously?
- A. Heparin
- B. Aminophylline (Truphylline)
- C. Nitroglycerin (Nitrodisc)
- D. Aspirin
Correct Answer: A
Rationale: Heparin is the standard anticoagulant used to prevent further clot formation in pulmonary embolism.