Nokea
Which of the following best indicates that the client's grief is beginning to resolve?
- A. The client wants only the spouse to visit.
- B. The client says the physician made an incorrect diagnosis.
- C. The client looks at the tracheostomy tube in a mirror.
- D. The client asks the nurse for help with bathing.
Correct Answer: C
Rationale: Looking at the tracheostomy tube in a mirror suggests acceptance of the body image change, indicating progress in resolving grief.
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The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include?
- A. Refer the client to the American Lung Association.
- B. Notify the physical therapy department to arrange for activity training.
- C. Arrange for oxygen therapy to be used at home.
- D. Discuss advance directives with the client.
Correct Answer: C
Rationale: Bronchiolitis obliterans causes irreversible airway obstruction, often requiring home oxygen therapy (C) to manage hypoxemia, a priority for discharge planning. Referrals (A), physical therapy (B), and advance directives (D) are important but secondary to ensuring oxygenation.
Which position is best for the client to be in while the nurse prepares to assess breath sounds?
- A. Sitting
- B. Standing
- C. Lying on the back
- D. Lying on the side
Correct Answer: A
Rationale: Sitting upright allows optimal lung expansion, making it easier to assess breath sounds accurately in a client with asthma.
You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gases below represent respiratory acidosis that is NOT compensated?
- A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
- B. pH 7.48, PaCO2 35, HCO3 22, PO2 85
- C. pH 7.20, PaCO2 20, HCO3 28, PO2 85
- D. pH 7.55, PaCO 63, HCO3 19, PO2 85
Correct Answer: A
Rationale: Respiratory acidosis is characterized by low pH (<7.35) and high PaCO2 (>45). Option A (pH 7.29, PaCO2 55, HCO3 23) shows uncompensated respiratory acidosis, as HCO3 is normal, indicating no renal compensation. Other options show normal pH, respiratory alkalosis, or invalid data.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.