Nokea
Which collaborative intervention should the nurse implement when caring for the client diagnosed with bronchiectasis?
- A. Prepare the client for an emergency tracheostomy.
- B. Discuss postoperative teaching for a lobectomy.
- C. Administer bronchodilators with postural drainage.
- D. Obtain informed consent form for chest tube insertion.
Correct Answer: C
Rationale: Bronchodilators with postural drainage (C) is a collaborative intervention for bronchiectasis to open airways and clear secretions, involving nursing and respiratory therapy. Tracheostomy (A) and lobectomy (B) are not standard. Chest tubes (D) are for pneumothorax, not bronchiectasis.
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Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
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 deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?
- A. Myocardial infarction.
- B. Pneumonia.
- C. Pulmonary embolus.
- D. Pneumothorax.
Correct Answer: C
Rationale: Sudden chest pain and impending doom in a DVT patient suggest pulmonary embolus (C), where a clot dislodges to the lungs, causing acute respiratory distress. Myocardial infarction (A) presents with cardiac symptoms. Pneumonia (B) has gradual onset. Pneumothorax (D) causes unilateral symptoms.
The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first?
- A. Take the client's vital signs.
- B. Check the client's pulse oximeter reading.
- C. Administer oxygen via nasal cannula.
- D. Notify the respiratory therapist STAT.
Correct Answer: C
Rationale: Administering oxygen (C) is the first intervention for a pneumonia patient with shortness of breath to correct hypoxemia, per the ABCs (airway, breathing, circulation). Checking pulse oximetry (B) assesses oxygenation but delays treatment. Vital signs (A) and notifying the therapist (D) are secondary to immediate oxygen delivery.
The nurse knows that the correct way to position the hands when performing the abdominal thrust maneuver is with the thumb side of the closed fist on which part of the victim's abdomen?
- A. Directly on the manubrium
- B. Above the xiphoid process
- C. Below the navel
- D. Below the sternum
Correct Answer: B
Rationale: Positioning the fist above the xiphoid process (below the sternum) ensures safe and effective abdominal thrusts to dislodge the obstruction.