Nokea
Which nursing action is essential before suctioning the client with a tracheostomy tube?
- A. Preoxygenating the client
- B. Maintaining the head in a flexed position
- C. Cleaning around the stoma
- D. Removing the inner cannula
Correct Answer: A
Rationale: Preoxygenating the client prevents hypoxia during suctioning, which can temporarily reduce oxygen intake.
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An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest x-ray. This indicated that at that time the client:
- A. was less susceptible to a tuberculosis infection than the year before.
- B. had acquired some degree of passive immunity to tuberculosis.
- C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis.
- D. had a mild tuberculosis infection in an organ other than the lung.
Correct Answer: C
Rationale: A positive PPD with a negative chest x-ray indicates exposure to Mycobacterium tuberculosis with an immune response but no active pulmonary disease.
A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed?
- A. Macrolide
- B. Cephalosporins
- C. Pencillin G
- D. Tamiflu
Correct Answer: A
Rationale: For gram-positive bacterial pneumonia in a penicillin-allergic patient, macrolides like azithromycin are commonly prescribed due to their efficacy and safety. Cephalosporins may cross-react with penicillin allergies, Penicillin G is contraindicated, and Tamiflu is for viral infections.
The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?
- A. Administer intravenous fluids of normal saline at 125 mL/hr.
- B. Provide supplemental oxygen per nasal cannula at 2 L/min.
- C. Continuous telemetry monitoring with strips every four (4) hours.
- D. Administer a loop diuretic intravenously every six (6) hours.
Correct Answer: A
Rationale: A mean pulmonary artery pressure of 35 mm Hg indicates pulmonary hypertension, common in end-stage COPD. IV fluids at 125 mL/hr (A) risk fluid overload and worsening right heart strain, so this order should be questioned. Oxygen (B), telemetry (C), and diuretics (D) are appropriate to manage hypoxia, monitor cardiac status, and reduce fluid overload.
Which priority intervention should the nurse implement for the client diagnosed with coal workers' pneumoconiosis?
- A. Monitor the client's intake and output.
- B. Assess for black-streaked sputum.
- C. Monitor the white blood cell count daily.
- D. Assess the client's activity level every shift.
Correct Answer: B
Rationale: Black-streaked sputum (B) is a hallmark of coal workers' pneumoconiosis due to coal dust deposition, making its assessment a priority to confirm disease impact. Intake/output (A) is non-specific. Daily WBC counts (C) are unnecessary unless infection is suspected. Activity level (D) is secondary to symptom assessment.
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?
- A. The client's pulse oximeter reading is 92%.
- B. The client's arterial blood gas level is 74.
- C. The client has SOB when walking to the bathroom.
- D. Rusty colored sputum.
Correct Answer: D
Rationale: Rusty sputum (D) suggests hemoptysis or infection, a critical finding in end-stage COPD. SpO2 92% (A), PaO2 74 (B), and SOB (C) are expected but less urgent.