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The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?
- A. Assist the patient to sit upright in a chair.
- B. Splint the patient's chest during coughing.
- C. Medicate the patient with prescribed morphine.
- D. Observe the patient use the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.
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A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
- A. Paradoxic chest movement
- B. Complaint of chest wall pain
- C. Heart rate of 110 beats/minute
- D. Large bruised area on the chest
Correct Answer: A
Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.
The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?
- A. I will make an appointment to see the doctor every year.
- B. I will stop taking the prednisone if I experience a dry cough.
- C. I will not worry if I feel a little short of breath with exercise.
- D. I will call the health care provider right away if I develop a fever.
Correct Answer: D
Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.
Which information about a 60-year-old patient with MS indicates that the nurse should consult with the healthcare provider before giving the prescribed dose of dalfampridine (Ampyra)?
- A. The patient has relapsing-remitting MS
- B. The patient walks a mile a day for exercise
- C. The patient complains of pain with neck flexion
- D. The patient has an increased serum creatinine level
Correct Answer: D
Rationale: The correct answer is that the patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function as it can worsen their condition. Options A, B, and C are unrelated to the administration of dalfampridine. The fact that the patient has relapsing-remitting MS, walks for exercise, or experiences neck pain does not directly impact the decision to administer dalfampridine. However, an increased serum creatinine level is a contraindication for this medication and requires consultation with the healthcare provider to determine the appropriate course of action.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
- A. Is there any family history of TB?
- B. How long have you lived in the United States?
- C. Do you take any over-the-counter (OTC) medications?
- D. Have you received the bacille Calmette-Guerin (BCG) vaccine for TB?
Correct Answer: D
Rationale: It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
- A. Teach about the reason for the blood tests.
- B. Schedule an appointment for a chest x-ray.
- C. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
- D. Instruct the patient to expectorate three specimens as soon as possible.
Correct Answer: C
Rationale: The correct action for the nurse to take is to teach the patient about the need to collect sputum specimens for 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. It is important to obtain these specimens on different days rather than all at once. Blood tests are not used for tuberculosis testing, so teaching about blood tests is not relevant. While a chest x-ray is important in tuberculosis diagnosis, it is not a bacteriologic test. The appearance on a chest x-ray alone is not sufficient to diagnose TB as other diseases can have similar findings.