Nokea
The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include?
- A. Refer the client to the American Lung Association.
- B. Notify the physical therapy department to arrange for activity training.
- C. Arrange for oxygen therapy to be used at home.
- D. Discuss advance directives with the client.
Correct Answer: C
Rationale: Bronchiolitis obliterans causes irreversible airway obstruction, often requiring home oxygen therapy (C) to manage hypoxemia, a priority for discharge planning. Referrals (A), physical therapy (B), and advance directives (D) are important but secondary to ensuring oxygenation.
You may also like to solve these questions
A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness?
- A. I have always enjoyed hot Mexican-style food.'
- B. I have smoked three packs of cigarettes a day for the last 40 years.'
- C. I used to work in a factory that burned coal.'
- D. I sang in the church choir every Sunday until my voice got hoarse last year.'
Correct Answer: B
Rationale: Cigarette smoking is the greatest risk factor for laryngeal cancer due to chronic exposure to carcinogens.
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first?
- A. Milk the chest tube.
- B. Check the tubing for kinks.
- C. Instruct the client to cough.
- D. Assess the insertion site.
Correct Answer: B
Rationale: No tidaling in the water-seal compartment suggests a blockage or kink. Checking for kinks (B) is the first, non-invasive action to restore function. Milking (A) is avoided due to pressure risks. Coughing (C) is ineffective if tubing is blocked. Assessing the site (D) is secondary.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?
- A. Notify the respiratory therapist immediately.
- B. Ventilate with a manual resuscitation bag.
- C. Request STAT arterial blood gases.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: Manual ventilation (B) ensures oxygenation during ventilator failure, a priority. Notification (A), ABGs (C), and auscultation (D) follow.