Nokea
You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
- A. Easily fatigued with physical activity
- B. Reduced peak flow meter reading
- C. Chest retractions
- D. Cyanosis
- E. Wheezing with activity
- F. Nighttime coughing
- G. No relief with short-acting bronchodilator inhaler
Correct Answer: A,B,E,F
Rationale: Early warning signs include fatigue, reduced peak flow, wheezing with activity, and nighttime coughing. Chest retractions, cyanosis, and no relief from a bronchodilator indicate a more severe attack.
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Which assessment data indicate to the nurse the client diagnosed with Legionnaires' disease is experiencing a complication?
- A. The client has an elevated body temperature.
- B. The client has less than 30 mL urine output an hour.
- C. The client has a decrease in body aches.
- D. The client has an elevated white blood cell count.
Correct Answer: B
Rationale: Oliguria (<30 mL/hr, B) indicates renal failure, a serious complication of Legionnaires' disease due to systemic infection or shock. Fever (A) and elevated WBC (D) are expected in active infection, not complications. Decreased body aches (C) suggests improvement, not a complication.
Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply.
- A. Perform postural drainage and percussion every four (4) hours.
- B. Modify activities to accommodate daily physiotherapy.
- C. Increase fluid intake to one (1) liter daily to thin secretions.
- D. Recognize and report signs and symptoms of respiratory infections.
- E. Avoid anyone suspected of having an upper respiratory infection.
Correct Answer: A,B,D,E
Rationale: Postural drainage (1) helps clear mucus in CF. Modifying activities for physiotherapy (2) ensures adherence. Recognizing infection signs (4) and avoiding respiratory infections (5) prevent exacerbations. One liter of fluid (3) is insufficient for children; fluid needs vary by age and size.
What is the significance of a positive tuberculin skin test?
- A. The client has an active infection.
- B. Antibodies are present in the client's blood.
- C. The client is immune to this type of disease.
- D. The client needs to be in strict isolation.
Correct Answer: B
Rationale: A positive tuberculin skin test indicates the presence of antibodies to tuberculosis, suggesting exposure or latent infection, not necessarily active disease.
The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse?
- A. The client has an intake of 1,500 mL IV and an output of 1,000 mL.
- B. The client has 450 mL of bright-red drainage in the chest tube.
- C. The client is complaining of pain at a '10' on a 1-to-10 scale.
- D. The client has absent lung sounds on the side of the surgery.
Correct Answer: B
Rationale: 450 mL bright-red drainage (B) suggests hemorrhage, requiring immediate action. Fluid balance (A), severe pain (C), and absent lung sounds (D) are expected or less urgent.
The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery?
- A. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
- B. The client has an oral temperature of 100.2°F and a dry cough.
- C. There are one (1) to two (2) white blood cells (WBCs) in the urinalysis.
- D. The client's current international normalized ratio (INR) is 1.
Correct Answer: B
Rationale: Fever (100.2°F) and cough (B) suggest infection, a surgical risk requiring HCP notification. Hb/Hct (A) are near normal, WBCs in urine (C) are insignificant, and INR 1 (D) is normal.