Nokea
Which information should the nurse teach the client diagnosed with acute sinusitis?
- A. Instruct the client to complete all the ordered antibiotics.
- B. Teach the client how to irrigate the nasal passages.
- C. Have the client demonstrate how to blow the nose.
- D. Give the client samples of a narcotic analgesic for the headache.
Correct Answer: A
Rationale: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.
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Which statement is correct regarding mycobacterium tuberculosis?
- A. This bacterium is an anaerobic type of bacteria.
- B. It is an alkali bacterium that stains bright red during an acidfast smear test.
- C. It is known as being an aerobic type of bacteria.
- D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.
Correct Answer: C
Rationale: Mycobacterium tuberculosis is an aerobic bacterium. It is acid-fast and stains red (not green) during an acid-fast smear due to its mycolic acid-rich cell wall. It is not anaerobic or alkali.
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse?
- A. Large amounts of thick white sputum.
- B. Oxygen flowmeter set on eight (8) liters.
- C. Use of accessory muscles during inspiration.
- D. Presence of a barrel chest and dyspnea.
Correct Answer: B
Rationale: High oxygen (8 LPM, B) risks CO2 retention in COPD, requiring immediate adjustment (2–4 LPM). Sputum (A), accessory muscles (C), and barrel chest (D) are expected but less urgent.
When the nurse is teaching a client to self-administer nose drops, which head position is appropriate?
- A. Bending the head forward, then instilling the drops
- B. Pushing the nose laterally, then instilling the drops
- C. Tilting the head backward, then instilling the drops
- D. Turning the head to the side, then instilling the drops
Correct Answer: C
Rationale: Tilting the head backward allows nose drops to reach the nasal passages effectively by gravity, ensuring proper distribution of the medication.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply.
- A. Keep protamine sulfate readily available.
- B. Avoid applying pressure to venipuncture sites.
- C. Assess for overt and covert signs of bleeding.
- D. Avoid invasive procedures and injections.
- E. Administer stool softeners as ordered.
Correct Answer: B,C,D
Rationale: Avoiding pressure (B), monitoring bleeding (C), and avoiding procedures (D) prevent hemorrhage during thrombolytics. Protamine (A) reverses heparin, and softeners (E) are unrelated.