Nokea
The nurse observes the client sitting on the side of the bed with the arms propped on the over-bed table. The chest is barrel shaped and the client is breathing though lips spaced close together and is exhaling slowly. Which concept is priority for this client?
- A. Mobility.
- B. Nutrition.
- C. Activity intolerance.
- D. Oxygenation.
Correct Answer: D
Rationale: Tripod position, barrel chest, and pursed-lip breathing (D) indicate COPD with oxygenation as the priority. Mobility (A), nutrition (B), and activity (C) are secondary.
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Which statement by the client best indicates that the client understands the rationale for the direct laryngoscopy?
- A. The test will tell if my hoarseness is caused by tracheal polyps.
- B. The physician says that hoarseness can lead to bronchitis.
- C. I need to have the test because hoarseness is a symptom of laryngeal cancer.
- D. The physician wants to see if my hoarseness is because of enlarged tonsils.
Correct Answer: C
Rationale: Persistent hoarseness can be a symptom of laryngeal cancer, and direct laryngoscopy is used to visualize the larynx for abnormalities like tumors.
Which statement is correct regarding mycobacterium tuberculosis?
- A. This bacterium is an anaerobic type of bacteria.
- B. It is an alkali bacterium that stains bright red during an acid-fast smear test.
- C. It is known as being an aerobic type of bacteria.
- D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.
Correct Answer: C
Rationale: Mycobacterium tuberculosis is AEROBIC (it thrives in conditions that are high in oxygen), and it is an ACID-FAST bacterium, which means when it is stained during an acid-fast smear it will turn BRIGHT RED.
A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis?
- A. He drinks raw milk.
- B. He cleans chicken houses.
- C. He handles fertilizer frequently.
- D. He stepped on a rusty nail recently.
Correct Answer: B
Rationale: Cleaning chicken houses exposes the client to bird droppings, a common source of Histoplasma capsulatum, the fungus causing histoplasmosis.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a surgical floor. Which information provided by the UAP requires immediate intervention by the nurse?
- A. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection.
- B. The client who has had a right upper lobectomy is complaining that the patient-controlled analgesia (PCA) pump is not providing any relief.
- C. The client diagnosed with cancer of the lung is complaining of being tired and short of breath.
- D. The client admitted with chronic obstructive pulmonary disease is making a whistling sound with every breath.
Correct Answer: A
Rationale: Bright-red drainage post-neck dissection (A) suggests hemorrhage, requiring immediate action. PCA failure (B), fatigue/SOB (C), and wheezing (D) are expected or less urgent.
Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM?
- A. pH 7.38, Pao2 94, Paco2 44, Hco3 24.
- B. pH 7.46, Pao2 82, Paco2 34, Hco3 22.
- C. pH 7.48, Pao2 59, Paco2 30, Hco3 26.
- D. pH 7.33, Pao2 94, Paco2 44, Hco3 20.
Correct Answer: C
Rationale: ARDS is characterized by severe hypoxemia despite high oxygen delivery. Pao2 59 (C) despite 10 LPM oxygen indicates refractory hypoxia, a hallmark of ARDS. Normal Pao2 (94 in A and D) contradicts ARDS. Pao2 82 (B) is low but not as severe as 59, making C the best indicator of ARDS.