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Which clinical manifestation would the nurse assess in the client newly diagnosed with intrinsic lung cancer?
- A. Dysphagia.
- B. Foul-smelling breath.
- C. Hoarseness.
- D. Weight loss.
Correct Answer: C
Rationale: Hoarseness (C) is a common early symptom of intrinsic lung cancer due to tumor compression of the recurrent laryngeal nerve. Dysphagia (A) is more typical of esophageal involvement. Foul-smelling breath (B) is non-specific. Weight loss (D) occurs later in advanced disease.
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Which nursing measure is most helpful in reducing the client's anxiety during an asthma attack?
- A. Close the door to the examination room.
- B. Remain within the client's view.
- C. Pull the bedside privacy curtain.
- D. Notify the client when the respiratory therapist arrives.
Correct Answer: B
Rationale: Remaining within the client's view provides reassurance and reduces anxiety by ensuring the client feels supported during an asthma attack.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
- A. Administer the ordered oral antibiotic immediately (STAT).
- B. Order the meal tray to be delivered as soon as possible.
- C. Obtain a sputum specimen for culture and sensitivity.
- D. Have the unlicensed assistive personnel weigh the client.
Correct Answer: C
Rationale: Obtaining sputum culture (C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (A) follow, meals (B) and weight (D) are less urgent.
Which health measure is most important to emphasize when instructing the client on ways to prevent transmitting tuberculosis?
- A. Eat a nutritious diet.
- B. Get adequate sleep.
- C. Cover your nose and mouth when coughing.
- D. Wash your hands before and after meals.
Correct Answer: C
Rationale: Covering the nose and mouth when coughing prevents the spread of tuberculosis, an airborne disease, to others.
The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
Correct Answer: 880
Rationale: Heparin rate: (20,000 units ÷ 500 mL) × 22 mL/hr = 40 units/mL × 22 mL/hr = 880 units/hr.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.