Nokea
Which of the following statements are incorrect about discharge teaching that you would provide to a patient with COPD? Select-all-that-apply:
- A. It is best to eat three large meals a day that are relatively low in calories.'
- B. Avoid going outside during extremely hot or cold days.'
- C. It is important to receive the Pneumovax vaccine annually.'
- D. Smoking cessation can help improve your symptoms.'
Correct Answer: A,C
Rationale: Eating small, frequent meals (not three large meals, A) prevents diaphragm compression, and Pneumovax is not annual but given once or as per guidelines. Avoiding extreme weather and smoking cessation are correct.
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The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS?
- A. Low arterial oxygen when administering high concentration of oxygen.
- B. The client has dyspnea and tachycardia and is feeling anxious.
- C. Bilateral breath sounds clear and pulse oximeter reading is 95%.
- D. The client has jugular vein distention and frothy sputum.
Correct Answer: A
Rationale: Refractory hypoxemia (A) despite high oxygen confirms ARDS. Dyspnea/tachycardia (B) are nonspecific, clear sounds/95% SpO2 (C) are normal, and JVD/sputum (D) suggest heart failure.
The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.
The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client?
- A. Complete blood count.
- B. Pulmonary function test.
- C. Allergy skin testing.
- D. Drug cortisol level.
Correct Answer: B
Rationale: Pulmonary function tests (B) assess airway obstruction in acute asthma. CBC (A), allergy testing (C), and cortisol levels (D) are not immediate diagnostic tools.
You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education?
- A. Cough for a minimum of 6 weeks
- B. Night sweats
- C. Weight gain
- D. Hemoptysis
- E. Chills
- F. Fever
- G. Chest pain
Correct Answer: B,D,E,F,G
Rationale: Option A is wrong because a cough should be present for 3 weeks or more (NOT 6 weeks). Option C is wrong because the patient will experience weight LOSS (not gain).
Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.