Nokea
Which side effect can the nurse expect when the client receives aminophylline (Truphylline)?
- A. Bronchospasm
- B. Hypotension
- C. Drowsiness
- D. Tachycardia
Correct Answer: D
Rationale: Aminophylline, a xanthine derivative, commonly causes tachycardia as a side effect due to its stimulatory effects.
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You're educating a patient with pneumonia how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device?
- A. Encourage the patient to use it twice a day.
- B. The patient exhales into the device rapidly and then coughs.
- C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
- D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
Correct Answer: C
Rationale: Correct incentive spirometer use involves slow, deep inhalation to maximize lung expansion, holding the breath for 6 seconds to keep alveoli open, and then exhaling . Other options describe incorrect techniques that don't promote effective lung expansion.
A client's PPD test is positive, and a chest x-ray is negative. What is the best interpretation of these data?
- A. The client's resistance to tuberculosis is low.
- B. The client has been exposed to the organism but has not developed the disease.
- C. The client has tuberculosis, but it is not serious.
- D. The client has active tuberculosis.
Correct Answer: B
Rationale: A positive PPD with a negative chest x-ray indicates exposure to tuberculosis without active disease.
Which statement by the client indicates an accurate understanding of the purpose of aerosol therapy?
- A. Aerosol therapy relieves tissue irritation.
- B. Aerosol therapy delivers medication directly to the lungs.
- C. Aerosolization dries respiratory passages.
- D. Aerosol therapy helps to slow breathing.
Correct Answer: B
Rationale: Aerosol therapy delivers medication directly to the lungs, targeting the respiratory tract for effective treatment of bronchitis.
The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which health-care provider order should the nurse implement first?
- A. Start IV with 1,000 mL 0.9% saline.
- B. Ceftriaxone 1 gm IVPB every 12 hours.
- C. Obtain sputum and blood cultures.
- D. CBC and basic metabolic panel.
Correct Answer: C
Rationale: Sputum/blood cultures (C) must be obtained before antibiotics to identify pathogens, a priority. IV fluids (A), antibiotics (B), and labs (D) follow.
After a chest tube has been inserted to treat the client's pneumothorax, which finding indicates that the chest tube is functioning correctly?
- A. The water in the suction control chamber is bubbling.
- B. The water seal chamber has continuous vigorous bubbling.
- C. The drainage system is positioned upright.
- D. The client reports relief of chest pain.
Correct Answer: D
Rationale: Relief of chest pain indicates the chest tube is effectively re-expanding the lung and resolving the pneumothorax.