Nokea
When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
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The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first?
- A. Milk the chest tube.
- B. Check the tubing for kinks.
- C. Instruct the client to cough.
- D. Assess the insertion site.
Correct Answer: B
Rationale: No tidaling in the water-seal compartment suggests a blockage or kink. Checking for kinks (B) is the first, non-invasive action to restore function. Milking (A) is avoided due to pressure risks. Coughing (C) is ineffective if tubing is blocked. Assessing the site (D) is secondary.
When suctioning the airway of a client with a tracheostomy, the nurse applies suction for no longer than how many seconds?
- A. 5 to 7
- B. 10 to 12
- C. 15 to 20
- D. 25 to 30
Correct Answer: B
Rationale: Suctioning for 10 to 12 seconds minimizes the risk of hypoxia and mucosal trauma.
You are providing teaching to a patient with chronic COPD on how to perform diaphragmatic breathing. This technique helps do the following:
- A. Increase the breathing rate to prevent hypoxemia
- B. Decrease the use of the abdominal muscles
- C. Encourages the use of accessory muscles to help with breathing
- D. Strengthen the diaphragm
Correct Answer: D
Rationale: Diaphragmatic breathing strengthens the diaphragm , improving breathing efficiency in COPD. It doesn't increase breathing rate , decrease abdominal muscle use , or encourage accessory muscle use .
The client has had a total laryngectomy. Which referral is specific for this surgery?
- A. CanSurmount.
- B. Dialogue.
- C. Lost Chord Club.
- D. SmokEnders.
Correct Answer: C
Rationale: Lost Chord Club (C) supports laryngectomy patients with communication and adjustment. CanSurmount (A), Dialogue (B), and SmokEnders (D) are for cancer, CLL, and smoking cessation.
While developing the postoperative care plan for the client, it is essential to have the client lie in which position?
- A. With the healthy lung uppermost
- B. With the head lower than the heart
- C. With the arms elevated on pillows
- D. On the operative side
Correct Answer: A
Rationale: Positioning with the healthy lung uppermost optimizes ventilation and perfusion in the remaining lung post-pneumonectomy.