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When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?
- A. Administer antibiotics
- B. Provide supplemental oxygen
- C. Administer antiviral medications
- D. Administer bronchodilators
Correct Answer: A
Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.
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When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?
- A. Air should be instilled into the monitoring system after the procedure.
- B. The client should be positioned on the left side after the procedure.
- C. The transducer should be level with the second intercostal space after the line is placed.
- D. A chest x-ray is needed to verify placement after the procedure.
Correct Answer: D
Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.
A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?
- A. Albuterol can increase my blood sugar levels.
- B. Albuterol can decrease my immune response.
- C. I can experience an increase in my heart rate while taking albuterol.
- D. I may develop mouth sores while taking albuterol.
Correct Answer: C
Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.
A healthcare professional in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the professional not expect?
- A. Bradycardia
- B. Cyanosis
- C. Hypotension
- D. Dyspnea
Correct Answer: A
Rationale: Bradycardia is not typically associated with a flail chest. Flail chest is characterized by paradoxical chest wall movement, respiratory distress, and hypoxia, but it does not usually cause bradycardia. The other options, such as cyanosis (bluish discoloration of the skin due to poor oxygenation), hypotension (low blood pressure), and dyspnea (difficulty breathing), are commonly seen in patients with flail chest due to the underlying respiratory compromise.
A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?
- A. Take quick breaths upon inhalation.
- B. Place your hand over your stomach.
- C. Take a deep breath in through your nose.
- D. Puff your cheeks upon exhalation.
Correct Answer: C
Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.
A healthcare professional is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The healthcare professional should not concentrate on which of the following adverse effects of this medication?
- A. Hypokalemia
- B. Tachycardia
- C. Fluid retention
- D. Black, tarry stools
Correct Answer: B
Rationale: When administering prednisone, a corticosteroid medication, to a client with COPD, the healthcare professional should be aware of potential adverse effects. Tachycardia is not a common adverse effect of prednisone use. The correct adverse effects to monitor for include hypokalemia, fluid retention, and gastrointestinal issues like black, tarry stools due to potential gastrointestinal bleeding. Therefore, the healthcare professional should not concentrate on tachycardia but should focus on the other listed adverse effects when administering prednisone to a client with COPD.