Nokea
The nurse is preparing the plan of care for the client who had a pleurodesis. Which collaborative intervention should the nurse include?
- A. Monitor the amount and color of drainage from the chest tube.
- B. Perform a complete respiratory assessment every two (2) hours.
- C. Administer morphine sulfate, an opioid analgesic, intravenously.
- D. Keep a sterile dressing and bottle of sterile normal saline at the bedside.
Correct Answer: A
Rationale: Pleurodesis involves sclerosing the pleural space to prevent fluid reaccumulation, often requiring a chest tube. Monitoring drainage amount and color (A) is a collaborative intervention to assess procedure success and detect complications. Respiratory assessment (B) and morphine administration (C) are nursing or medical orders, not collaborative. Keeping sterile supplies (D) is preparatory, not a primary intervention.
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The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates more teaching is required?
- A. It doesn't matter if I smoke now. I already have cancer.
- B. I should see the oncologist at my scheduled appointment.
- C. If I begin to run a fever, I should notify the HCP.
- D. I should plan for periods of rest throughout the day.
Correct Answer: A
Rationale: Continued smoking (A) worsens lung cancer outcomes, indicating a need for teaching. Follow-ups (B), fever reporting (C), and rest (D) are correct.
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: Streptomycin can cause ototoxicity, leading to symptoms like ringing in the ears (tinnitus). This requires immediate physician notification to prevent further hearing damage.
The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple ecchymotic areas on the arms. Based on the assessment data, which question should the nurse ask the client?
- A. Do you take prednisone?
- B. Can you tell me who hurts you?
- C. May I check your coccyx for pressure areas?
- D. Do you sleep with the head of the bed elevated?
Correct Answer: A
Rationale: Thin limbs, truncal obesity, and ecchymosis (A) suggest corticosteroid use (e.g., prednisone) in COPD. Abuse (B), pressure ulcers (C), and HOB elevation (D) are less likely.
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority?
- A. Wound infection.
- B. Hemorrhage.
- C. Respiratory distress.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Respiratory distress (C) is life-threatening post-laryngectomy, a priority. Infection (A), hemorrhage (B), and knowledge deficit (D) are secondary.