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When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.
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You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing?
- A. Peak flow meter; pneumonia
- B. Incentive spirometer; thrush
- C. Spacer; thrush
- D. Peak flow meter; mouth sores
Correct Answer: C
Rationale: A spacer helps deliver Budesonide, an inhaled corticosteroid, more effectively to the lungs, reducing the risk of oral thrush by minimizing medication deposition in the mouth.
Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain?
- A. Medicate the client and have the client take deep breaths.
- B. Encourage the client to take shallow breaths to help with the pain.
- C. Explain deep breaths do not have to be taken at this time.
- D. Tell the client if he doesn't take deep breaths, he could die.
Correct Answer: A
Rationale: Pain medication followed by deep breathing (A) prevents atelectasis. Shallow breaths (B), delaying (C), and fear tactics (D) are inappropriate.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
The nurse knows to discontinue the client's sponge bath if the client develops which symptom?
- A. Nausea
- B. Chills
- C. Flushing
- D. Confusion
Correct Answer: B
Rationale: Chills during a sponge bath indicate the client is becoming too cold, which can worsen discomfort and should prompt discontinuation.