Nokea
Which nursing intervention is most important in response to the client's physical symptoms at this time?
- A. Administering oxygen by face mask
- B. Assessing the client's capillary refill
- C. Having the client rate the pain on a pain scale
- D. Requesting a physician's order for cardiac enzymes
Correct Answer: A
Rationale: Administering oxygen addresses hypoxia, a critical concern in pulmonary embolism due to impaired gas exchange.
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A client's PPD test is positive, and a chest x-ray is negative. What is the best interpretation of these data?
- A. The client's resistance to tuberculosis is low.
- B. The client has been exposed to the organism but has not developed the disease.
- C. The client has tuberculosis, but it is not serious.
- D. The client has active tuberculosis.
Correct Answer: B
Rationale: A positive PPD with a negative chest x-ray indicates exposure to tuberculosis without active disease.
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
- A. Assist the client into a sitting position at 90 degrees.
- B. Administer oxygen at six (6) LPM via nasal cannula.
- C. Monitor vital signs with the client sitting upright.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sitting upright (A) improves lung expansion in COPD distress, a priority. Oxygen (B), vitals (C), and notification (D) follow to support oxygenation and communication.
Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital?
- A. Avoid smoking and exposure to smoke.
- B. Do not receive flu or pneumonia vaccines.
- C. Avoid any type of alcohol intake.
- D. It will take about one (1) month to recuperate.
Correct Answer: A
Rationale: Avoiding smoke (A) prevents further lung damage, a priority post-ARDS. Vaccines (B) are recommended, alcohol (C) is not restricted, and recovery time (D) varies.
A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
- A. It produces greater blood oxygen levels.
- B. It is easier to breathe through the nose.
- C. The nares humidify, warm, and filter the air.
- D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Correct Answer: C
Rationale: The nares humidify, warm, and filter air, improving its quality for respiration.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: This is how an AFB sputum culture is collected.