Nokea
Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?
- A. Alteration in comfort.
- B. Altered level of consciousness.
- C. Alteration in elimination pattern.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Pain (alteration in comfort, A) is a common issue post-thoracotomy due to surgical incision and chest tube placement, making it the most appropriate nursing diagnosis on day one. Altered consciousness (B) is not typical unless complications arise. Elimination issues (C) are less immediate. Knowledge deficit (D) is relevant later for discharge teaching.
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When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
Which referral is most appropriate for a client diagnosed with end-stage COPD?
- A. The Asthma Foundation of America.
- B. The American Cancer Society.
- C. The American Lung Association.
- D. The American Heart Association.
Correct Answer: C
Rationale: The American Lung Association (C) supports COPD patients with resources. Asthma Foundation (A), Cancer Society (B), and Heart Association (D) are less relevant.
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45, Paco2 54, Hco3 25, Pao2 52. Which should the nurse implement? Select all that apply.
- A. Apply oxygen via nonrebreather mask.
- B. Call the rapid response team (RRT).
- C. Elevate the head of the bed.
- D. Stay with the client.
- E. Notify the health-care provider (HCP).
Correct Answer: A,B,C,D,E
Rationale: PaO2 52 and PaCO2 54 indicate severe hypoxia; apply nonrebreather (A), call RRT (B), elevate HOB (C), stay with client (D), and notify HCP (E) are all critical.
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply.
- A. Place the client in the low Fowler's position.
- B. Assess chest tube drainage system frequently.
- C. Maintain strict bedrest for the client.
- D. Secure a loop of drainage tubing to the sheet.
- E. Observe the site for subcutaneous emphysema.
Correct Answer: B
Rationale: Frequent system checks (B), securing tubing (D), and monitoring emphysema (E) ensure chest tube function. Low Fowler’s (A) is incorrect (semi-Fowler’s preferred), and bedrest (C) is unnecessary.
The charge nurse is making rounds. Which client should the nurse assess first?
- A. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude.
- B. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities.
- C. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL.
- D. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.
Correct Answer: C
Rationale: Blood glucose 189 mg/dL in DKA (C) indicates potential instability, requiring immediate assessment. Rudeness (A), edema (B), and stable COPD (D) are less urgent.