Nokea
Until the client can be examined later that morning, which advice by the nurse would be most helpful?
- A. Sucking on ice chips should help.
- B. Rest your voice.
- C. Massage your throat.
Correct Answer: B
Rationale: Resting the voice reduces strain on the vocal cords, which is beneficial for laryngitis and helps prevent further irritation.
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A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
- A. Demonstrate the correct technique for giving a bed bath.
- B. Encourage the UAP to put the bed in the lowest position.
- C. Instruct the UAP to get another person to help with the bath.
- D. Provide praise for performing the bath safely for the client and the UAP.
Correct Answer: B
Rationale: Lowering the bed (B) prevents falls, critical for ARDS patients. Demonstration (A), extra help (C), and praise (D) are inappropriate given safety concerns.
You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gases below represent respiratory acidosis that is NOT compensated?
- A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
- B. pH 7.48, PaCO2 35, HCO3 22, PO2 85
- C. pH 7.20, PaCO2 20, HCO3 28, PO2 85
- D. pH 7.55, PaCO 63, HCO3 19, PO2 85
Correct Answer: A
Rationale: Respiratory acidosis is characterized by low pH (<7.35) and high PaCO2 (>45). Option A (pH 7.29, PaCO2 55, HCO3 23) shows uncompensated respiratory acidosis, as HCO3 is normal, indicating no renal compensation. Other options show normal pH, respiratory alkalosis, or invalid data.
The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach?
- A. Demonstrate the proper method of gargling with normal saline.
- B. Perform voice exercises for 30 minutes three (3) times a day.
- C. Explain that a lighted instrument will be placed in the throat to biopsy the area.
- D. Teach the client to self-examine the larynx monthly.
Correct Answer: C
Rationale: Laryngoscopy with biopsy (C) diagnoses laryngeal cancer, requiring client education. Gargling (A), voice exercises (B), and self-examination (D) are not diagnostic.
The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
- A. Bronchovesicular lung sounds and bradypnea.
- B. Unequal lung expansion and dyspnea.
- C. Frothy, bloody sputum and consolidation.
- D. Barrel chest and polycythemia.
Correct Answer: B
Rationale: Pneumothorax causes unequal lung expansion and dyspnea (B) from collapsed lung. Bronchovesicular sounds/bradypnea (A), frothy sputum (C), and barrel chest (D) suggest other conditions.