Nokea
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
- A. Cough productive of yellow sputum.
- B. Bilateral expiratory wheezing.
- C. Chest tightness.
- D. Respiratory rate of 30 breaths/minute.
Correct Answer: A
Rationale: A productive cough with yellow sputum suggests a respiratory infection, which can exacerbate asthma. Wheezing, chest tightness, and tachypnea are typical asthma symptoms, not specific to infection.
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A client receiving chemotherapy has experienced a flare-up of pruritus. In order to develop a care plan, the nurse should ask the client if she has been:
- A. Wearing clothes made from 100% cotton.
- B. Sleeping in a cool, humidified room.
- C. Increasing fluid intake to at least 3,000 mL/day.
- D. Taking daily baths with a deodorant soap.
Correct Answer: B
Rationale: Sleeping in a cool, humidified room can reduce pruritus by preventing skin dryness, which is a key factor in developing an effective care plan.
The nurse is assessing a client receiving intravenous (IV) fluids via a peripheral vascular access device (PVAD). Assessment findings show swelling and tenderness at the infusion site. The nurse should perform which action?
- A. stop the infusion and remove the PVAD
- B. remove the dressing and reposition the PVAD
- C. instruct the client to perform range of motion activities in the affected arm
- D. place the arm in a dependent position
Correct Answer: A
Rationale: Swelling and tenderness indicate infiltration, requiring stopping the infusion and removing the PVAD.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
Postoperative nursing management of the client following a radical neck dissection for laryngeal cancer requires:
- A. Complete bed rest minimizing head movement.
- B. Vital signs once a shift.
- C. A. All the nurse should be made to be removed at 48 hours.
- D. Frequent suctioning of the laryngectomy tube.
Correct Answer: D
Rationale: Frequent suctioning of the laryngectomy tube prevents mucus buildup and maintains airway patency. Complete bed rest is unnecessary; early mobility is encouraged. Vital signs should be monitored more frequently than once per shift. The third option is unclear but likely incorrect.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?
- A. Tay-Sachs cells.
- B. Reed-Sternberg cells.
- C. Duchenne's cells.
- D. None of the above
Correct Answer: B
Rationale: Hodgkin's disease is diagnosed by the presence of Reed-Sternberg cells, large multinucleated cells, in the lymph node biopsy. Tay-Sachs and Duchenne's cells are unrelated to Hodgkin's.