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Which nursing observation provides the best evidence that postural drainage is effective?
- A. The client's respiratory rate is increased.
- B. The client's heart rate is much improved.
- C. The client's sputum culture is negative.
- D. The client raises a large volume of sputum.
Correct Answer: D
Rationale: Raising a large volume of sputum indicates that postural drainage is effectively clearing secretions from the airways.
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The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.
Which data are significant when assessing a client diagnosed with rule-out Legionnaires' disease?
- A. The amount of cigarettes smoked a day and the age when started.
- B. Symptoms of aching muscles, high fever, malaise, and coughing.
- C. Exposure to a saprophytic water bacterium transmitted into the air.
- D. Decreased bilateral lung sounds in the lower lobes.
Correct Answer: B
Rationale: Symptoms like aching muscles, high fever, malaise, and coughing (B) are characteristic of Legionnaires' disease, a severe pneumonia. Smoking history (A) is non-specific. Exposure to Legionella (C) is a risk factor, not a clinical datum. Decreased lung sounds (D) are less specific than systemic symptoms.
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
In regards to question 10, which action by the patient demonstrates they know how to properly use this medication?
- A. The patient rinses their mouth after using the Spiriva inhaler.
- B. The patient rinses their mouth after using the Pulmicort inhaler.
- C. The patient dispenses of the inhalers.
- D. The patient coughs 2 times after using the Pulmicort inhaler.
Correct Answer: B
Rationale: Pulmicort (corticosteroid) requires mouth rinsing to prevent oral thrush. Spiriva doesn't require rinsing, and coughing or disposing are incorrect.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.