Nokea
Which action is most appropriate for the nurse to take before the bronchoscopy?
- A. Keep the client NPO for at least 6 hours.
- B. Have the client cough several times.
- C. Ensure that the client gets adequate sleep.
- D. Scrub the client's upper chest with an antiseptic.
Correct Answer: A
Rationale: Keeping the client NPO for at least 6 hours prevents aspiration during bronchoscopy, which involves sedation.
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A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD test (8 mm induration) indicates TB exposure but does not confirm active disease. A chest X-ray and sputum culture are needed to differentiate latent from active TB before treatment or precautions are initiated.
Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply:
- A. Stridor
- B. Coarse crackles
- C. Oxygen saturation less than $90 \%$
- D. Non-productive, nagging cough
- E. Elevated white blood cells
- F. Low PCO2 of less than 35
- G. Tachypnea
Correct Answer: B,C,E,G
Rationale: Pneumonia typically presents with coarse crackles due to fluid in alveoli, low oxygen saturation from impaired gas exchange, elevated WBCs indicating infection, and tachypnea (G) as a compensatory mechanism. Stridor is associated with upper airway obstruction, non-productive cough is less common, and low PCO2 suggests hyperventilation, not typical.
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain?
- A. Number of years the client has smoked.
- B. Risk factors for complications.
- C. Ability to administer inhaled medication.
- D. Willingness to modify lifestyle.
Correct Answer: C
Rationale: Correct inhaler use (C) ensures effective COPD management, a priority for health promotion. Smoking history (A), risk factors (B), and lifestyle (D) are important but secondary.
Which statement by the client best indicates that the client understands the rationale for the direct laryngoscopy?
- A. The test will tell if my hoarseness is caused by tracheal polyps.
- B. The physician says that hoarseness can lead to bronchitis.
- C. I need to have the test because hoarseness is a symptom of laryngeal cancer.
- D. The physician wants to see if my hoarseness is because of enlarged tonsils.
Correct Answer: C
Rationale: Persistent hoarseness can be a symptom of laryngeal cancer, and direct laryngoscopy is used to visualize the larynx for abnormalities like tumors.
When administering oxygen to the client through a partial rebreathing mask, which observation is most important for the nurse to report to the respiratory therapy department?
- A. Moisture is accumulating inside the mask.
- B. The bag collapses during inspiration.
- C. The mask covers the client's mouth and nose.
- D. The strap around the client's head is snug.
Correct Answer: B
Rationale: A collapsing bag during inspiration indicates inadequate oxygen flow, which must be reported to ensure proper oxygen delivery.