Nokea
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment?
- A. Assess the client's bilateral lung sounds.
- B. Obtain an order for a STAT chest x-ray.
- C. Notify the health-care provider as soon as possible.
- D. Document the findings in the client's chart.
Correct Answer: A
Rationale: No tidaling may indicate resolution or obstruction; assessing lung sounds (A) confirms status. CXR (B), notification (C), and documentation (D) follow.
You may also like to solve these questions
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.
A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD?
- A. Emphysema
- B. Pneumonia
- C. Chronic bronchitis
- D. Pneumothorax
Correct Answer: C
Rationale: Chronic bronchitis , a type of COPD, is characterized by chronic productive cough, hypoxemia, hypercapnia, cyanosis, and edema from right heart failure. Emphysema typically shows barrel chest, pneumonia is an infection, and pneumothorax involves lung collapse.
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 discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.