A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

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Question 1 of 5

A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

Correct Answer: A

Rationale: The correct answer is A: Decreased breath sounds on the affected side. In a pleural effusion, fluid accumulates in the pleural space, leading to decreased air entry and diminished breath sounds on auscultation. This occurs because the fluid dampens the transmission of sound through the lungs. B: Hyperresonance on percussion of the affected side is not expected in pleural effusion, as it is typically associated with conditions like pneumothorax. C: Increased tactile fremitus on the affected side is not a typical finding in pleural effusion. Tactile fremitus may be decreased due to the presence of fluid. D: Tracheal deviation toward the affected side is more commonly seen in conditions like tension pneumothorax, not pleural effusion.

Question 2 of 5

A client is experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?

Correct Answer: A

Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms. Summary of other choices: B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief. C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations. D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations

Question 3 of 5

A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

Correct Answer: C

Rationale: The correct answer is C. Administer oxygen to maintain saturations above 94%. In asthma exacerbation, maintaining oxygen saturation is crucial to prevent hypoxia. Oxygen therapy helps improve oxygen delivery to tissues and organs. Administering salmeterol (choice A) may help with long-term management but is not an immediate priority. Tracheal deviation assessment (choice B) is not relevant to asthma exacerbation. Performing peak expiratory flow measurements (choice D) may be helpful for monitoring asthma severity but is not the priority in this acute situation.

Question 4 of 5

A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

Correct Answer: B

Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent further complications. The other choices are incorrect because: A: Production of pink sputum may indicate blood-tinged sputum, which could be a sign of minor bleeding but does not require immediate intervention. C: Pain at insertion site is common after chest tube insertion and can be managed with pain medication, not necessarily requiring immediate intervention. D: Sudden onset of shortness of breath could indicate various issues, including pneumothorax, but tracheal deviation is a more specific and urgent sign that requires immediate attention.

Question 5 of 5

A client with chronic obstructive pulmonary disease is being taught by a nurse. Which nutritional information should the nurse include in the teaching? (SATA)

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. High-fiber foods promote gastric emptying, reducing the risk of bloating and discomfort in COPD patients. 2. COPD patients may experience difficulty breathing, leading to decreased physical activity and slower digestion. 3. Consuming high-fiber foods helps regulate bowel movements and prevents constipation, common in COPD patients. Summary of Incorrect Choices: A: Avoiding fluids just before and during meals is not specific to COPD patients and may not directly address their nutritional needs. B: Resting before meals if experiencing dyspnea may be helpful, but it does not address specific nutritional information. C: Having six small meals a day may be beneficial for some COPD patients, but it does not directly address the importance of high-fiber foods for promoting gastric emptying.

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