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Which data are significant when assessing a client diagnosed with rule-out Legionnaires' disease?
- A. The amount of cigarettes smoked a day and the age when started.
- B. Symptoms of aching muscles, high fever, malaise, and coughing.
- C. Exposure to a saprophytic water bacterium transmitted into the air.
- D. Decreased bilateral lung sounds in the lower lobes.
Correct Answer: B
Rationale: Symptoms like aching muscles, high fever, malaise, and coughing (B) are characteristic of Legionnaires' disease, a severe pneumonia. Smoking history (A) is non-specific. Exposure to Legionella (C) is a risk factor, not a clinical datum. Decreased lung sounds (D) are less specific than systemic symptoms.
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The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
- A. Bronchovesicular lung sounds and bradypnea.
- B. Unequal lung expansion and dyspnea.
- C. Frothy, bloody sputum and consolidation.
- D. Barrel chest and polycythemia.
Correct Answer: B
Rationale: Pneumothorax causes unequal lung expansion and dyspnea (B) from collapsed lung. Bronchovesicular sounds/bradypnea (A), frothy sputum (C), and barrel chest (D) suggest other conditions.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
- A. Taking the client's temperature
- B. Assessing the client's blood pressure
- C. Monitoring the client's respiratory status
- D. Checking the client's pupillary response
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.
The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.
The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance?
- A. The most difficult time of the day for me is the first hour after waking up in the morning.'
- B. I feel best in the morning after a good night's sleep.'
- C. I seem to have more energy after eating a big meal.'
- D. I don't know why, but I get my 'second wind' at night and don't want to go to bed.'
Correct Answer: A
Rationale: Morning fatigue is common in COPD due to mucus accumulation and poor sleep, affecting activity tolerance.