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The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.
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Immediately after the specimen is drawn, the registered nurse instructs the licensed practical nurse to perform which essential action?
- A. Apply direct pressure to the site for 5 minutes.
- B. Warm the blood in the specimen tube for 5 minutes.
- C. Assess the client's blood pressure in 5 minutes.
- D. Elevate the client's arm for at least 5 minutes.
Correct Answer: A
Rationale: Applying direct pressure to the radial artery puncture site for 5 minutes prevents bleeding and hematoma formation.
A patient with emphysema may present with all of the following symptoms EXCEPT?
- A. Barrel chest
- B. Hyperinflation of the lungs
- C. Hypoventilation
- D. Hypercapnia
Correct Answer: C
Rationale: Emphysema causes barrel chest , lung hyperinflation , and often hypercapnia due to air trapping. Hypoventilation is not typical, as patients hyperventilate to compensate for poor gas exchange.
The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach?
- A. Demonstrate the proper method of gargling with normal saline.
- B. Perform voice exercises for 30 minutes three (3) times a day.
- C. Explain that a lighted instrument will be placed in the throat to biopsy the area.
- D. Teach the client to self-examine the larynx monthly.
Correct Answer: C
Rationale: Laryngoscopy with biopsy (C) diagnoses laryngeal cancer, requiring client education. Gargling (A), voice exercises (B), and self-examination (D) are not diagnostic.
Which position is best for the client to be in while the nurse prepares to assess breath sounds?
- A. Sitting
- B. Standing
- C. Lying on the back
- D. Lying on the side
Correct Answer: A
Rationale: Sitting upright allows optimal lung expansion, making it easier to assess breath sounds accurately in a client with asthma.
What nursing action is most appropriate when administering both types of oral medication to this client?
- A. Administer the cough syrup first, then the tablets.
- B. Wait 15 minutes after giving the cough syrup before giving the tablets.
- C. Give the cough syrup between administering the tablets.
- D. Administer the tablets first, then the cough syrup.
Correct Answer: D
Rationale: Administering tablets first ensures they are swallowed properly, followed by the cough syrup, which may coat the throat and aid swallowing.