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The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem 'altered communication.' Which intervention should the nurse implement?
- A. Instruct the client to drink a mixture of brandy and honey several times a day.
- B. Encourage the client to whisper instead of trying to speak at a normal level.
- C. Provide the client with a blank note pad for writing any communication.
- D. Explain that the client's aphonia may become a permanent condition.
Correct Answer: C
Rationale: A note pad (C) facilitates communication during laryngitis-related voice loss. Brandy/honey (A) is unproven, whispering (B) strains vocal cords, and permanent aphonia (D) is unlikely.
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The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
- A. The test will confirm the results of the MRI.
- B. The client can eat and drink immediately after the test.
- C. The HCP can do a biopsy of the tumor through the scope.
- D. There is no discomfort associated with this procedure.
Correct Answer: C
Rationale: Bronchoscopy allows biopsy (C) to diagnose lung cancer. It doesn’t confirm MRI (A), requires NPO post-procedure (B), and causes discomfort (D).
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
You're educating a patient with pneumonia how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device?
- A. Encourage the patient to use it twice a day.
- B. The patient exhales into the device rapidly and then coughs.
- C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
- D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
Correct Answer: C
Rationale: Correct incentive spirometer use involves slow, deep inhalation to maximize lung expansion, holding the breath for 6 seconds to keep alveoli open, and then exhaling . Other options describe incorrect techniques that don't promote effective lung expansion.
Which pulse oximetry reading indicates to the nurse that the client has normal tissue oxygenation?
- A. 80 to 90 mm Hg
- B. 95 to 100 mm Hg
- C. 80% to 85%
- D. 95% to 100%
Correct Answer: D
Rationale: A pulse oximetry reading of 95% to 100% indicates normal tissue oxygenation, reflecting adequate oxygen saturation.
The nurse knows to discontinue the client's sponge bath if the client develops which symptom?
- A. Nausea
- B. Chills
- C. Flushing
- D. Confusion
Correct Answer: B
Rationale: Chills during a sponge bath indicate the client is becoming too cold, which can worsen discomfort and should prompt discontinuation.