Nokea
What intervention should a nurse use when the client is unable to cough and raise secretions?
- A. Give the client water to drink.
- B. Pat the client on the back.
- C. Gently suction the client.
- D. Give the client cough syrup.
Correct Answer: C
Rationale: Gentle suctioning effectively removes secretions, preventing respiratory complications.
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On assessing Mr. Puff, what would you expect to find?
- A. ‘Blue bloater’ appearance
- B. Copious amount of thin sputum
- C. Increased anteroposterior chest diameter
- D. Prolonged inspiratory time
Correct Answer: C
Rationale: The correct answer is C: Increased anteroposterior chest diameter. In patients with chronic obstructive pulmonary disease (COPD), like Mr. Puff, there is often air trapping leading to hyperinflation of the lungs. This results in an increased anteroposterior chest diameter, known as a "barrel chest" appearance. Option A (‘Blue bloater’ appearance) is associated with chronic bronchitis, not necessarily COPD. Option B (Copious amount of thin sputum) is more indicative of bronchiectasis. Option D (Prolonged inspiratory time) is a nonspecific finding and not typically associated with COPD.
Which of the following would you include as risk factors for the development of skin cancer when assessing the integumentary system?
- A. Advancing age
- B. Positive family history
- C. Dark pigmentation
- D. White collar job
Correct Answer: B
Rationale: Advancing age by itself is not a risk factor. If that person has been exposed to a lot of sun there may be increased risk, but that information is not given here. There is a known genetic risk, with some cancers being seen to be present in families with low risk factors. Those with dark pigmentation develop skin cancer, but at a lower rate than those with low amounts of pigmentation. White collar jobs, which occur in offices and inside buildings, are a low risk for skin cancer.
What outcome criterion would best reflect achievement of avoiding infections for Mr. Puff?
- A. Explains reason for avoiding aerosol sprays and powders
- B. Explains reason for avoiding unnecessary physical activity
- C. Lists causative organisms of bronchial infections
- D. States rationale for avoiding crowds when influenza or colds are prevalent
Correct Answer: D
Rationale: Avoiding crowded places minimizes exposure to respiratory pathogens.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but should be performed by the RN (select all that apply)?
- A. Administering patient medications
- B. Ambulating stable patients
- C. Performing patient assessment
- D. Evaluating the effectiveness of patient care
Correct Answer: A
Rationale: Medication administration, assessment, evaluation, and teaching require the RN's specialized knowledge and accountability.