What is the primary reason for a client with COPD to avoid smoking?
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Solution
Answer D is correct. Cigarette smoking directly affects the sweeping action of the cilia, which interferes with the ability to remove mucus and clear the airway. The answers in A and B are not specific to COPD. Answer C is not a direct effect of smoking.
The nurse is assessing a client after a car accident. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?
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Solution
Answer C is correct. Cyanosis and loss of consciousness will occur later as the obstruction worsens. Answers B and D are both earlier symptoms of obstruction. Answer A is not a definite clinical manifestation of obstruction.
A client with a subdural hematoma is receiving Mannitol and Lasix. The nurse recognizes that these two drugs are given to reverse which effect?
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Solution
Answer C is correct. Lasix and Mannitol are given for their diuretic effects to decrease cerebral edema. Answers A, B, and D are not effects of the drugs in this stem.
Which clinical manifestation would the nurse expect if a client was experiencing right-sided congestive heart failure?
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Solution
Answer A is correct. The increase in venous pressure causes the jugular veins to distend. Other symptoms of right-sided heart failure include ascites, weakness, anorexia, dependent edema, and weight gain. The answers in B, C, and D result from the left ventricle’s inability to pump blood out of the ventricle to the body and are specific for left-sided heart failure.
A client has sustained damage to the preoccipital lobe. The nurse should remain particularly alert for which of the following problems?
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Solution
Answer A is correct. The occipital lobe is the visual lobe. If the client were having problems with the occipital lobe, it would mean that the edema, bleeding, and so on was increasing to that area. Answers B, C, and D do not relate to the occipital lobe.
The nurse has received a report from the RN on several clients with respiratory problems. Upon receiving the following client reports, which client should be seen first?
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Solution
Answer C is correct. This client is exhibiting symptoms of heart failure. The client in answer A is being discharged, and a PO2 of 85, as in answer D, would not be a cause for alarm in a COPD client. The client in answer B would not require immediate attention.
The nurse is caring for a client with myasthenias gravis who is having trouble breathing. Which position would assist the client to breathe best?
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Solution
Answer D is correct. Sitting or positioning the client in high Fowler’s is best to assist the client in using respiratory muscles to breathe and lift the diaphragm from the abdominal area. Answer A would be contraindicated, and answers B and C would not help as much as answer D for breathing.
The nurse is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment findings include a respiratory rate of 40, a heart rate of 126, and restlessness. Which associated assessment finding would require immediate intervention?
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Solution
Answer C is correct. The absent breath sound and subcutaneous air, increased heart rate, dyspnea, and restlessness indicates a pneumothorax that would require immediate intervention. Answer A could occur with the pulmonary contusion and would be expected. Answer D, pain after breathing deeply, would be expected with fractured ribs. Answer B is not cause for great concern (the midline trachea is a normal finding).
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client will probably be placed on a mechanical ventilator?
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Solution
Answer C is correct. The pH is an accurate indicator of acute ventilatory failure and a need for mechanical ventilation. An elevated PCO2 , as in answer A, is not an adequate criterion for institution of ventilator support. Answer B, an oxygen saturation of 90, would not be very abnormal for a COPD client. Answer D is normal.
A client with Prinzmetal angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
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Solution
Answer A is correct. Imitrex results in cranial vasoconstriction to reduce pain, but it can also cause vasoconstrictive effects systemically. This drug is contraindicated in clients with angina, and the physician should be notified. Answers B and D are inappropriate actions from the information given. Answer C is appropriate, but answer A is most appropriate.