Nokea
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
- A. The most difficult time of the day for me is the first hour after waking up in the morning.'
- B. I feel best in the morning after a good night's sleep.'
- C. I seem to have more energy after eating a big meal.'
- D. I don't know why, but I get my 'second wind' at night and don't want to go to bed.'
Correct Answer: A
Rationale: Morning fatigue is common in COPD due to mucus accumulation and poor sleep, affecting activity tolerance.
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The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.
Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:
- A. Apply cool compresses to affected extremity
- B. Measure leg circumference
- C. Massage affected extremity
- D. Elevate affected extremity above heart level
- E. Encourage frequent ambulation
- F. Monitor the patient's INR level
- G. Monitor the patient's aPTT level
Correct Answer: B,D,G
Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.
The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
- A. Bronchovesicular lung sounds and bradypnea.
- B. Unequal lung expansion and dyspnea.
- C. Frothy, bloody sputum and consolidation.
- D. Barrel chest and polycythemia.
Correct Answer: B
Rationale: Pneumothorax causes unequal lung expansion and dyspnea (B) from collapsed lung. Bronchovesicular sounds/bradypnea (A), frothy sputum (C), and barrel chest (D) suggest other conditions.
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?
- A. Pleuritic chest discomfort and anxiety.
- B. Asymmetrical chest expansion and pallor.
- C. Leukopenia and CRT <three (3) seconds.
- D. Substernal chest pain and diaphoresis.
Correct Answer: A
Rationale: Pneumonia causes pleuritic chest pain and anxiety (A) from inflammation/hypoxia. Asymmetry (B) suggests pneumothorax, leukopenia (C) is atypical, and substernal pain (D) suggests MI.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.