A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

Correct Answer: D

Rationale: The correct answer is D because the trachea shifted towards the opposite side indicates a potential pneumothorax, a serious complication following thoracentesis. Immediate action is needed to prevent respiratory distress. Choices A and B are common post-procedural findings and may not require immediate action. Choice C, while indicating hypoxemia, does not pose an immediate threat compared to a tracheal deviation.

Correct Answer: C

Rationale: The correct answer is C: "I will take this medication on an empty stomach." This indicates effective teaching because isoniazid should be taken on an empty stomach to maximize absorption. Taking it with food can reduce absorption. A: Taking extra vitamin C is not necessary for isoniazid. B: Taking isoniazid with milk or juice can reduce its effectiveness. D: Contact lenses are not affected by isoniazid, so they will not be permanently stained.

Correct Answer: B

Rationale: In the context of a multiple-choice question about risk factors for laryngeal cancer, understanding why certain options are correct or incorrect requires a strong grasp of the respiratory system and its associated conditions. Option B, tobacco use, is the correct answer for being a risk factor for laryngeal cancer. Tobacco smoke contains numerous carcinogens that can damage the cells of the larynx, leading to cancer development. Option A, acute laryngitis, is incorrect as it is an inflammation of the larynx typically caused by viral infections or vocal strain, not a direct risk factor for cancer. Option C, caffeine use, is also incorrect as caffeine consumption is not directly linked to an increased risk of laryngeal cancer. Option D, sleep apnea, is incorrect as it is a sleep disorder characterized by pauses in breathing during sleep and is not a known risk factor for laryngeal cancer. Educationally, this question serves to reinforce the importance of understanding the specific risk factors associated with laryngeal cancer, emphasizing the detrimental effects of tobacco use on respiratory health. By analyzing each option critically, learners can enhance their knowledge of the respiratory system and its related pathologies.

Correct Answer: C

Rationale: In this scenario, the appropriate action to delegate to the experienced LPN/LVN is option C: Assist the client with basic activities of daily living (ADLs). The rationale for choosing option C is that assisting the client with basic ADLs directly addresses the nursing diagnosis of Ineffective Breathing Pattern in a practical way. By helping the client with activities such as bathing, dressing, and grooming, the LPN/LVN can ensure that the client conserves energy, minimizes exertion, and maintains optimal breathing patterns. Options A, B, and D are not the most appropriate actions to delegate in this case. Option A focuses on observing a specific breathing technique, which may not directly address the client's overall needs related to ADLs and breathing pattern. Option B involves planning a care regimen to increase activity tolerance, which is important but may not be as immediate or essential as assisting with ADLs. Option D, consulting with physical therapy about reconditioning exercises, is important for overall care but does not directly address the immediate ADL needs of the client with COPD and an Ineffective Breathing Pattern diagnosis. From an educational perspective, understanding the rationale behind delegating tasks based on client needs and nursing diagnoses is crucial for nurses and nursing students. It reinforces the importance of prioritizing care tasks, considering individual patient needs, and effective delegation within the healthcare team to provide comprehensive and patient-centered care.

Correct Answer: C

Rationale: In this multiple-choice question about the respiratory system, the correct answer is C) Percussion. Percussion is a technique used in physical examination to assess the density of underlying tissues by tapping on the body surface. Dullness and hyperresonance are abnormal findings that can be detected through percussion. Dullness indicates denser tissue, such as an organ, while hyperresonance indicates hollow or air-filled structures. Option A) Inspection involves visually examining the patient for any abnormalities, such as skin color or breathing pattern. Option B) Palpation involves using hands to feel for abnormalities like tenderness or masses. Option D) Auscultation involves listening to sounds produced by the body, such as breath and heart sounds. Understanding the correct assessment technique for specific abnormal findings is crucial in diagnosing respiratory conditions. By knowing the principles of percussion and recognizing the significance of dullness and hyperresonance, healthcare professionals can accurately assess and diagnose respiratory disorders. This knowledge is essential for medical students, nurses, and other healthcare providers to provide effective patient care.