NR-324 Adult Health I
NR 324: Exam 1 Practice Quiz
A client is experiencing 8/10 incisional pain, resulting in a poor cough effort, and has course scattered rhonchi after a thoracotomy. Which action should the nurse take first?
a. Medicate the patient with prescribed pain medication.
b....
NR-324 Adult Health I
NR 324: Exam 1 Practice Quiz
A client is experiencing 8/10 incisional pain, resulting in a poor cough effort, and has course scattered rhonchi after a thoracotomy. Which action should the nurse take first?
a. Medicate the patient with prescribed pain medication.
b. Splint the patient’s chest during coughing.
c. Observe the patient use the incentive spirometer.
d. Assess the patient’s oxygenation using a pulse oximetry.
RATIONALE: When we look at the data in this question, the client is having a poor
cough effort due to the pain. If we can take care of the pain, the client should be able to have a better cough effort, expel mucous, and the rhonchi would clear up. The other options might be interventions we would also perform; however, they would not resolve the problem.
The nurse is worried that a patient who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this patient?
a. IV drug administration
b. Remain in the hospital
c. Direct observation therapy
d. Isolation
RATIONALE: Direct observation therapy is the best way to ensure clients are taking their tuberculosis medications. The most important intervention we can do as nurses caring for clients with TB, is to ensure medication compliance. In direct
observation therapy, a person drives to the client's house and administers the medication each day.
The emergency department nurse is assessing a patient who has sustained a blunt injury to the right chest wall. Which findings indicate the presence of a pneumothorax? (Select all that apply)
a. Decreased chest expansion on the right side
b. The presence of a barrel chest
c. Diminished or absent breath sounds on the affected side
d. Tachypnea
e. Tachycardia
RATIONALE: Diminished or absent breath sounds on the affected side is correct because the lung is collapsed, so you will not hear lung sounds over that lung.
Decreased chest expansion on the affected side is correct because again, the lung is collapsed and will not expand.
Tachycardia and tachypnea will occur due to the lack of gas exchange. The heart will start pumping faster to try to perfuse the body with whatever oxygenated blood it has, and the respiratory rate will increase to try to get more oxygen in.
The presence of barrel chest is not associated with a pneumothorax. It is a physiological change that we see in patients with COPD.
A nurse is caring for a client with pneumonia who has a new tracheostomy requiring frequent suctioning. The nurse anticipates what possible clinical problems? (Select all that apply)
a. Acute pain
b. Hyponatremia
c. Impaired gas exchange
d. Fluid volume deficit
e. Ineffective airway clearance
RATIONALE: Impaired gas exchange is correct due to consolidation in the lungs, leaving less available surface area in the alveoli for gas exchange.
Ineffective airway clearance is correct due to the client having a new trach, requiring frequent suctioning. This indicates that the client cannot clear their own
secretions.
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