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While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
- A. Assess for drainage from the site.
- B. Cover the insertion site with sterile gauze.
- C. Contact the provider and obtain a suture kit.
- D. Reinsert the tube using sterile technique.
Correct Answer: B
Rationale: Covering the insertion site with sterile gauze prevents air from entering the pleural space, which could cause a pneumothorax. Assessing drainage, contacting the provider, or reinserting the tube are secondary actions after securing the site to prevent complications.
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A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching?
- A. Take an antibiotic each day.
- B. Contact your provider to obtain genetic screening.
- C. Eat a well-balanced, nutritious diet.
- D. Perform daily respiratory therapy exercises.
Correct Answer: C
Rationale: Clients with CF often experience malnourishment due to vitamin deficiency and pancreatic malfunction. A well-balanced, nutritious diet is essential for maintaining health. Daily antibiotics are not typically required, genetic screening is not relevant for management, and while respiratory therapy is important, it is not listed as an option.
The nurse is caring for a client with lung cancer who states, 'I don't want any pain medication because I am afraid to become addicted.' How should the nurse respond?
- A. I will ask the provider to change your medication to a drug that is less potent.
- B. I will ask the provider to prescribe a non-opioid analgesic.
- C. It is unlikely you will become addicted when taking medicine for pain.
- D. I will discuss alternative pain relief methods like acupuncture.
Correct Answer: C
Rationale: The risk of addiction is low when pain medications are used appropriately for pain management in clients with cancer. Changing to a less potent drug or non-opioid may not adequately address pain. Alternative methods like acupuncture may be considered but are not the priority response.
A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.)
- A. What color is your sputum?
- B. Do you have any difficulty sleeping?
- C. How long does it take to perform your morning routine?
- D. Do you walk up stairs every day?
- E. Have you lost any weight lately?
Correct Answer: B,C,E
Rationale: Difficulty sleeping, prolonged morning routines, and weight loss indicate worsening dyspnea or fatigue, reflecting activity tolerance. Sputum color and stair climbing frequency are less directly related to activity tolerance.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
- A. Encourage rinsing the mouth after fluticasone administration.
- B. Obtain an oral specimen for culture and sensitivity.
- C. Start the client on a broad-spectrum antibiotic.
- D. Document the finding as a known side effect.
Correct Answer: A
Rationale: Fluticasone reduces local immunity, increasing the risk of oral infections like Candida albicans. Rinsing the mouth after inhaler use decreases this risk. Obtaining a culture, starting antibiotics, or only documenting the finding do not address prevention or immediate management.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
- A. When the tube drainage increases and warms to the touch.
- B. When the tube drainage decreases and becomes sanguineous.
- C. When the client experiences pain at the insertion site.
- D. When the tube becomes disconnected from the drainage system.
Correct Answer: D
Rationale: A disconnected chest tube allows air to enter the pleural space due to negative intrathoracic pressure, causing a pneumothorax. Warm drainage, sanguineous drainage, or pain at the insertion site do not directly increase pneumothorax risk.