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When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?
- A. Assess the client's pain.
- B. Obtain a large-bore IV needle for decompression.
- C. Administer lorazepam.
- D. Prepare for chest tube insertion.
Correct Answer: B
Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.
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A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?
- A. A client who has a BMI of 30
- B. A female client who is postmenopausal
- C. A client who has a fractured femur
- D. A client who has chronic atrial fibrillation
Correct Answer: B
Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.
A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
- B. ''I will lie on my back with my knees bent.''
- C. ''I will rest my hand over my abdomen to create resistance.''
- D. ''I will take in a deep breath and hold it before exhaling.''
Correct Answer: D
Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.
A healthcare professional is reviewing the health records of five clients. Which of the following clients is not at risk for developing acute respiratory distress syndrome?
- A. A client who experienced a near-drowning incident
- B. A client following coronary artery bypass graft surgery
- C. A client who has a hemoglobin of 15.1 g/dL
- D. A client who has dysphagia
Correct Answer: C
Rationale: Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be triggered by various factors such as near-drowning incidents, surgeries like coronary artery bypass graft, and underlying conditions like dysphagia. Hemoglobin levels do not directly influence the risk of developing ARDS. A hemoglobin level of 15.1 g/dL falls within the normal range and does not predispose an individual to ARDS.
When teaching a client with tuberculosis, which statement should the nurse include?
- A. You will need to continue taking the multi-medication regimen for 4 months.
- B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.
- C. You will need to remain hospitalized for treatment.
- D. You will need to wear a mask at all times.
Correct Answer: B
Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.
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.