Nokea
While developing the postoperative care plan for the client, it is essential to have the client lie in which position?
- A. With the healthy lung uppermost
- B. With the head lower than the heart
- C. With the arms elevated on pillows
- D. On the operative side
Correct Answer: A
Rationale: Positioning with the healthy lung uppermost optimizes ventilation and perfusion in the remaining lung post-pneumonectomy.
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Until the client can be examined later that morning, which advice by the nurse would be most helpful?
- A. Sucking on ice chips should help.
- B. Rest your voice.
- C. Massage your throat.
Correct Answer: B
Rationale: Resting the voice reduces strain on the vocal cords, which is beneficial for laryngitis and helps prevent further irritation.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.
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 client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
- A. Administer the ordered oral antibiotic immediately (STAT).
- B. Order the meal tray to be delivered as soon as possible.
- C. Obtain a sputum specimen for culture and sensitivity.
- D. Have the unlicensed assistive personnel weigh the client.
Correct Answer: C
Rationale: Obtaining sputum culture (C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (A) follow, meals (B) and weight (D) are less urgent.
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.