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Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
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The client diagnosed with cancer of the larynx has had four (4) weeks of radiation therapy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain?
- A. The cancer has grown to obstruct the esophagus.
- B. The treatments are working on the cancer and the throat is edematous.
- C. Cancers are painful and this is expected.
- D. The treatments are also affecting the esophagus, causing ulcerations.
Correct Answer: D
Rationale: Radiation causes esophageal mucositis/ulcerations (D), leading to painful swallowing. Obstruction (A), edema (B), and cancer pain (C) are less likely causes.
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of 'impaired gas exchange.' Which is an expected outcome for this problem?
- A. Performs chest physiotherapy three (3) times a day.
- B. Able to complete activities of daily living.
- C. Ambulates in the hall several times during each shift.
- D. Alert and oriented to person, place, time, and events.
Correct Answer: D
Rationale: Alert/oriented status (D) indicates improved oxygenation from resolved gas exchange impairment. Physiotherapy (A) is an intervention, ADLs (B) and ambulation (C) are secondary outcomes.
The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?
- A. Do not abruptly stop taking this medication; it must be tapered off.
- B. Immediately rinse the mouth following administration of the drug.
- C. Hold the medication in the mouth for 15 seconds before swallowing.
- D. Take the medication immediately when an attack starts.
Correct Answer: B
Rationale: Rinsing the mouth (B) prevents oral thrush from inhaled glucocorticoids. Tapering (A) applies to systemic steroids, holding/swallowing (C) is incorrect, and attack use (D) is for rescue inhalers.
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 asthma is taking Theophylline. Which product below should the patient avoid consuming?
- A. Caffeine
- B. Dairy
- C. Wheat
- D. Shellfish
Correct Answer: A
Rationale: Caffeine can increase theophylline levels, leading to toxicity, as both are xanthine derivatives.