Nokea
Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply:
- A. Stridor
- B. Coarse crackles
- C. Oxygen saturation less than $90 \%$
- D. Non-productive, nagging cough
- E. Elevated white blood cells
- F. Low PCO2 of less than 35
- G. Tachypnea
Correct Answer: B,C,E,G
Rationale: Pneumonia typically presents with coarse crackles due to fluid in alveoli, low oxygen saturation from impaired gas exchange, elevated WBCs indicating infection, and tachypnea (G) as a compensatory mechanism. Stridor is associated with upper airway obstruction, non-productive cough is less common, and low PCO2 suggests hyperventilation, not typical.
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The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply.
- A. Assess the client's level of consciousness.
- B. Monitor urine output every shift.
- C. Turn the client every two (2) hours.
- D. Maintain intravenous fluids as ordered.
- E. Place the client in the Fowler's position.
Correct Answer: A,C,D,E
Rationale: LOC assessment (A), turning (C), IV fluids (D), and Fowler’s position (E) support ARDS care. Urine output (B) should be monitored hourly, not per shift.
The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement?
- A. Praise the UAP because this prevents the client from tripping on the oxygen tubing.
- B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
- C. Explain to the UAP in front of the client oxygen must be left in place at all times.
- D. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Correct Answer: B
Rationale: COPD clients need continuous oxygen; replacing it (B) corrects the error safely. Praising (A) is incorrect, explaining in front of client (C) is unprofessional, and escalating (D) is premature.
The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax?
- A. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
- B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
- C. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
- D. A tension pneumothorax results from a puncture of the pleura during a central line placement.
Correct Answer: C
Rationale: Tension pneumothorax traps air in the pleural space (C), increasing pressure. Bleb rupture (A) causes simple pneumothorax, free air movement (B) is open pneumothorax, and central line (D) is a cause, not definition.
You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: A,C,D,E,F
Rationale: Risk factors for tuberculosis include conditions or environments that weaken the immune system or increase exposure: diabetes , long-term care residency , incarceration , IV drug use , and HIV . Liver failure is not a direct risk factor, and being a U.S. resident is not specific enough.
The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach?
- A. Investigational regimens provide a better chance of survival for the client.
- B. Investigational treatments have not been proven to be helpful to clients.
- C. Clients will be paid to participate in an investigational program.
- D. Only clients who are dying qualify for investigational treatments.
Correct Answer: B
Rationale: Investigational treatments (B) lack proven efficacy, requiring informed consent. Better survival (A), payment (C), and terminal status (D) are incorrect.