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While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)
- A. What response do you have when you eat avocados?
- B. I will remove any avocados that are on your food tray
- C. Ask about the last time you ate avocados
- D. I will document this in your record so all of your providers will know
- E. Have you ever been treated for this allergic reaction?
Correct Answer: A,D,E
Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.
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A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercises?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: An equal AP and lateral chest diameter suggests a barrel chest, often associated with chronic airflow limitation conditions like COPD or severe asthma. Asking about chronic breathing problems directly addresses the potential underlying cause. Other options are less relevant to this specific finding.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)
- A. Withhold bronchodilator medication
- B. The client is ready to go down to radiology for this examination
- C. Physical therapy states the client can run on a treadmill
- D. The client has not smoked in the last 6 hours
- E. The client is alert and can follow your commands
Correct Answer: A,D,E
Rationale: Withholding bronchodilators, confirming no recent smoking, and ensuring the client can follow commands are essential for accurate PFTs. PFTs are performed at the bedside, not in radiology, and a treadmill is not used.
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate
- B. Crackles are heard in the trachea. The nurse encourages the client to cough perfectly
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply
Correct Answer: C
Rationale: Wheezes indicate narrowed airways, and an inhaled bronchodilator is the appropriate intervention to open air passages. Hollow sounds over the trachea are normal, crackles may require diuresis rather than coughing, and vesicular sounds in the periphery are normal, requiring no intervention.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. Oxygen saturation is 92% after a 12-minute walk
- B. A small amount of drainage from the site is noted
- C. Pulse oximetry is 95% on 2 liters of oxygen
- D. The trachea is deviated toward the opposite side of the neck
Correct Answer: D
Rationale: A deviated trachea indicates a tension pneumothorax, a medical emergency requiring immediate intervention. Other findings, such as small drainage or 95% pulse oximetry, are normal or near-normal and do not require urgent action.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
- A. Encourage the client to increase fluid intake
- B. Assess the clients level of consciousness
- C. Raise the head of the bed to at least 45 degrees
- D. Provide the client with humidified oxygen
Correct Answer: B
Rationale: Assessing the client's level of consciousness is critical as it indicates how the client is responding to the infection and its impact on overall health. While encouraging fluid intake, raising the head of the bed, and providing humidified oxygen are important interventions, they are secondary to assessing consciousness, which can reveal urgent changes in the client's condition.