Nokea
Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain?
- A. Medicate the client and have the client take deep breaths.
- B. Encourage the client to take shallow breaths to help with the pain.
- C. Explain deep breaths do not have to be taken at this time.
- D. Tell the client if he doesn't take deep breaths, he could die.
Correct Answer: A
Rationale: Pain medication followed by deep breathing (A) prevents atelectasis. Shallow breaths (B), delaying (C), and fear tactics (D) are inappropriate.
You may also like to solve these questions
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
The nurse is planning the care of a client diagnosed with asthma and has written a problem of 'anxiety.' Which nursing intervention should be implemented?
- A. Remain with the client.
- B. Notify the health-care provider.
- C. Administer an anxiolytic medication.
- D. Encourage the client to drink fluids.
Correct Answer: A
Rationale: Remaining with the client (A) reduces anxiety through presence and reassurance. Notification (B), anxiolytics (C), and fluids (D) are secondary or unrelated.
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.
The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
- A. The test will confirm the results of the MRI.
- B. The client can eat and drink immediately after the test.
- C. The HCP can do a biopsy of the tumor through the scope.
- D. There is no discomfort associated with this procedure.
Correct Answer: C
Rationale: Bronchoscopy allows biopsy (C) to diagnose lung cancer. It doesn’t confirm MRI (A), requires NPO post-procedure (B), and causes discomfort (D).
Your patient with asthma is taking Theophylline. Which product below should the patient avoid consuming?
- A. Caffeine
- B. Dairy
- C. Wheat
- D. Shellfish
Correct Answer: A
Rationale: Caffeine can increase theophylline levels, leading to toxicity, as both are xanthine derivatives.