Nokea
The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions?
- A. Telling the client to take deep breaths
- B. Striking the back with a cupped hand
- C. Applying pressure below the diaphragm
- D. Placing the client in a sitting position
Correct Answer: B
Rationale: Striking the back with a cupped hand (percussion) helps loosen secretions during postural drainage.
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The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?
- A. Administer the narcotic analgesic intravenous push (IVP).
- B. Perform gentle oral hygiene.
- C. Place the client in semi-Fowler's position.
- D. Assess the client's pain.
Correct Answer: D
Rationale: Pain assessment (D) is the first step to determine severity and guide treatment. Narcotics (A), oral hygiene (B), and positioning (C) follow based on assessment.
Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: Pyrazinamide can cause hyperuricemia, leading to gout symptoms (pain, redness, swelling in joints like the big toe). The physician will likely order a uric acid level to confirm this side effect.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply.
- A. Keep protamine sulfate readily available.
- B. Avoid applying pressure to venipuncture sites.
- C. Assess for overt and covert signs of bleeding.
- D. Avoid invasive procedures and injections.
- E. Administer stool softeners as ordered.
Correct Answer: B,C,D
Rationale: Avoiding pressure (B), monitoring bleeding (C), and avoiding procedures (D) prevent hemorrhage during thrombolytics. Protamine (A) reverses heparin, and softeners (E) are unrelated.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.
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.