Absent breath sounds on the right side suggest what treatment?

Correct Answer: C

Rationale: The correct answer is C) Chest tube and drainage. Absent breath sounds on the right side suggest a potential pneumothorax or hemothorax, which necessitates intervention to remove air or blood from the pleural space. A chest tube allows for drainage and re-expansion of the affected lung, addressing the underlying issue causing the absent breath sounds. Option A) Bronchodilators would not be the appropriate treatment for absent breath sounds due to a pneumothorax or hemothorax. Bronchodilators are typically used to treat conditions like asthma or COPD where there is bronchoconstriction, not for resolving issues related to lung collapse or fluid accumulation. Option B) Mechanical ventilation would be necessary if the patient's respiratory status deteriorates to the point where they are unable to ventilate adequately on their own. However, it is not the primary treatment for resolving absent breath sounds in the context of a pneumothorax or hemothorax. Option D) Cardiac tamponade treatment is unrelated to the management of absent breath sounds on the right side. Cardiac tamponade involves fluid accumulation around the heart, leading to impaired cardiac function, and would present with different clinical manifestations than absent breath sounds due to lung pathology. In an educational context, understanding the significance of absent breath sounds and the appropriate interventions is crucial for nurses and healthcare professionals caring for patients with respiratory issues. This knowledge is especially relevant for nurses preparing for the NCLEX exam, as they need to be able to differentiate between various respiratory conditions and understand the appropriate nursing interventions for each. Mastering this content ensures safe and effective patient care in clinical practice.

Correct Answer: D

Rationale: The correct answer, D) Walk 15-20 minutes 3 times a week, is the most appropriate exercise regimen recommended for a COPD patient due to its emphasis on regular, moderate aerobic activity. Walking helps strengthen respiratory muscles, improves cardiovascular health, and enhances overall endurance without placing excessive stress on the lungs. This regimen strikes a balance between promoting physical activity and managing the potential limitations posed by COPD. Option A) Rest when short of breath is incorrect as it promotes a sedentary lifestyle, which can lead to deconditioning and worsen COPD symptoms. Option B) Limit to ADLs may not provide adequate cardiovascular exercise needed to improve oxygenation. Option C) High-intensity daily is not suitable for COPD patients as it can trigger severe shortness of breath and exacerbate symptoms. Educationally, it is crucial for healthcare providers to understand the significance of tailored exercise regimens for patients with COPD. By promoting evidence-based recommendations like walking 15-20 minutes 3 times a week, providers can empower patients to actively engage in managing their condition and improve their quality of life. Encouraging regular, moderate exercise not only benefits physical health but also promotes mental well-being and independence for individuals with COPD.

Correct Answer: A

Rationale: Rationale: The correct answer is A) 320. Peak Expiratory Flow Rate (PEFR) measures the maximum speed at which a person can exhale air. A PEFR less than 80% of the personal best indicates the patient is in the yellow zone, signaling a cautionary stage where changes in therapy are necessary to prevent worsening airway constriction. Option B) 400, Option C) 500, and Option D) 600 are incorrect because they exceed the 80% threshold. In conditions like asthma, a PEFR value below 80% of the personal best indicates a decline in lung function and signals the need for treatment adjustments. Therefore, options B, C, and D would falsely suggest the patient is not in the yellow zone, potentially delaying necessary interventions. In an educational context, understanding PEFR values is crucial for healthcare professionals, especially those dealing with patients with respiratory conditions. Knowledge of PEFR ranges and zones helps in assessing the severity of airway narrowing, guiding treatment decisions, and preventing exacerbations. Educating students on interpreting PEFR values equips them with essential skills for managing patients with respiratory issues effectively.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Disorientation and tremors. In respiratory acidosis, the primary issue is the retention of carbon dioxide, leading to an increase in CO2 levels in the blood and subsequent decrease in pH. Disorientation and tremors are key manifestations of this condition due to the central nervous system's sensitivity to changes in pH levels. These symptoms may progress to more severe neurological manifestations like seizures and decreased level of consciousness. Option B) Tachycardia and decreased blood pressure are not characteristic of respiratory acidosis. In fact, respiratory acidosis typically leads to a compensatory response of increased heart rate and blood pressure in an attempt to improve oxygenation and decrease CO2 levels. Option C) Increased anxiety and irritability are more commonly associated with respiratory alkalosis, where there is a decrease in CO2 levels leading to respiratory compensation and consequent symptoms like anxiety, palpitations, and dizziness. Option D) Hyperventilation and lethargy are not typical manifestations of respiratory acidosis. Hyperventilation is more commonly seen in respiratory alkalosis as a compensatory mechanism to decrease CO2 levels, while lethargy may result from the CNS depression associated with hypercapnia in respiratory acidosis. Educational Context: Understanding the manifestations of respiratory acidosis is crucial for nurses caring for patients with respiratory conditions. Recognizing these signs early can prompt appropriate interventions to improve oxygenation and ventilation, preventing further complications. By linking pathophysiology to clinical presentation, nurses can provide effective care and support to patients experiencing respiratory acidosis.

Correct Answer: A

Rationale: The correct answer is A) Teach the client about cobalamin therapy. This is the best action by the nurse because a sore tongue (glossitis) is a classic symptom of B12 deficiency, also known as pernicious anemia. Cobalamin therapy involves the administration of vitamin B12 to address the deficiency and alleviate symptoms like glossitis. Educating the client about this therapy is crucial for promoting their understanding of the condition and its treatment. Option B) Ordering genetic testing for the client is incorrect because the symptoms presented (sore tongue and inability to eat) are indicative of a nutritional deficiency rather than a genetic condition. Genetic testing would not be the appropriate next step in this scenario. Option C) Encouraging a high-fiber diet is also incorrect as this would not directly address the underlying cause of the client's symptoms, which is a B12 deficiency. While a healthy diet is important for overall well-being, it would not be the primary intervention needed in this case. Option D) Placing the client on protective precautions is not relevant to the client's symptoms of a sore tongue and inability to eat. Protective precautions are typically implemented to prevent the spread of infections and would not be indicated in this situation. In an educational context, it is essential for nurses to be able to recognize common signs and symptoms of various health conditions, such as glossitis in the context of B12 deficiency. Understanding the rationale behind treatment options is crucial for providing effective care to clients and promoting positive health outcomes. Educating clients about their conditions and treatment options empowers them to take an active role in managing their health.