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The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS?
- A. Low arterial oxygen when administering high concentration of oxygen.
- B. The client has dyspnea and tachycardia and is feeling anxious.
- C. Bilateral breath sounds clear and pulse oximeter reading is 95%.
- D. The client has jugular vein distention and frothy sputum.
Correct Answer: A
Rationale: Refractory hypoxemia (A) despite high oxygen confirms ARDS. Dyspnea/tachycardia (B) are nonspecific, clear sounds/95% SpO2 (C) are normal, and JVD/sputum (D) suggest heart failure.
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When the client asks the nurse about why the physician has prescribed two drugs, which response is most accurate?
- A. One medication diminishes the side effects of the other.
- B. One medication kills the live organism; the other, its spores.
- C. Using combined medications can reduce the dosages of both drugs.
- D. Using two or more drugs lowers the potential for bacterial resistance.
Correct Answer: D
Rationale: Combination therapy (rifampin and isoniazid) reduces the risk of bacterial resistance, ensuring effective tuberculosis treatment.
You're educating a patient with pneumonia how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device?
- A. Encourage the patient to use it twice a day.
- B. The patient exhales into the device rapidly and then coughs.
- C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
- D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
Correct Answer: C
Rationale: Correct incentive spirometer use involves slow, deep inhalation to maximize lung expansion, holding the breath for 6 seconds to keep alveoli open, and then exhaling . Other options describe incorrect techniques that don't promote effective lung expansion.
Which assessment finding indicates that the client has most likely developed pleurisy as a result of the pneumonia?
- A. Productive cough
- B. Pain when breathing
- C. Cyanotic nail beds
- D. Rapid heart rate
Correct Answer: B
Rationale: Pleurisy causes sharp chest pain during breathing due to inflammation of the pleural membranes.
Which nursing action is essential during tracheal suctioning?
- A. Using a lubricant such as petroleum jelly
- B. Administering 100% oxygen before and after suctioning
- C. Making sure the suction catheter is open or on during insertion
- D. Assisting the client to assume a supine position during suctioning
Correct Answer: B
Rationale: Administering 100% oxygen before and after suctioning prevents hypoxia during the procedure.
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: This is how an AFB sputum culture is collected.