An older adult client with emphysema who continues to smoke cigarettes returns to the medical unit after a physical therapy session, and is short of breath. The nurse notes that the client is lying supine with the head of the bed elevated to 45 degrees. Oxygen is flowing via nasal cannula at 3L/minute. The client's pulse oximetry is 88%, respiratory rate is 14 breaths/minute, and vital signs are stable. Which intervention should the nurse implement?

Assess lung sounds for signs of infection.

Encourage client to initiate a smoking cessation program.

Administer a prescribed albuterol inhaler.

Notify the healthcare provider of the low pulse oximetry value.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Assess lung sounds for signs of infection: While lung assessment is important, there's no indication of fever or increased sputum to suggest infection. It does not immediately relieve the client's current dyspnea.

B. Encourage client to initiate a smoking cessation program: Smoking cessation is vital but is a long-term intervention and not appropriate as the first action for acute shortness of breath following exertion.

C. Administer a prescribed albuterol inhaler: Albuterol acts as a bronchodilator and can relieve acute shortness of breath due to bronchospasm or exertional dyspnea in clients with emphysema. This is the most immediate and appropriate action.

D. Notify the healthcare provider of the low pulse oximetry value: Although communication with the provider may be needed if symptoms persist, the pulse ox of 88% can be common in COPD clients. Immediate symptom relief with the prescribed bronchodilator is the priority.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Prepare a new water-seal system and reattach the chest tube: After temporarily placing the disconnected tube in sterile water to prevent air entry, the priority is to re-establish a closed drainage system to maintain negative intrathoracic pressure and prevent complications like tension pneumothorax.

B. Clamp the chest tube and maintain its distal end in the water: Clamping a chest tube can increase the risk of tension pneumothorax by trapping air inside the pleural cavity. It should only be done momentarily and under specific circumstances.

C. Apply pressure to the chest tube site using a petroleum gauze: This is appropriate if the chest tube becomes dislodged from the insertion site, not if it's disconnected from the drainage system. The insertion site remains intact in this case.

D. Begin manual ventilation while returning the client to the bed: There is no indication of respiratory distress or collapse requiring manual ventilation. The immediate need is to restore the chest tube drainage system.

A. Family history B. Hypertension C. Obesity D. High cholesterol E. Age F. Male gender G. Coronary artery disease H. Tobacco use

Correct Answer is ["B","C","D","G","H"]

Explanation

Rationale:

A. Family history: A family history of aneurysms or vascular disease is a non-modifiable risk factor. While it provides valuable context for risk assessment, it cannot be changed through behavioral interventions.

B. Hypertension: Elevated blood pressure contributes significantly to the development and progression of aortic aneurysms. Teaching the client to manage blood pressure through medications, diet, and lifestyle is essential to reducing further vascular damage.

C. Obesity: Excess body weight increases the strain on the cardiovascular system and is associated with elevated blood pressure, insulin resistance, and atherosclerosis. Weight management strategies should be emphasized in post-discharge education.

D. High cholesterol: Hyperlipidemia accelerates atherosclerosis, which weakens arterial walls and promotes aneurysm formation. Dietary changes, medication adherence, and lipid monitoring are important components of long-term care.

E. Age: Advancing age is a major risk factor for aortic aneurysms, especially in individuals over 65. However, it is non-modifiable and therefore not the focus of preventive teaching.

F. Male gender: Being male increases the risk of developing abdominal aortic aneurysms compared to females, but gender is non-modifiable. Patient education should instead focus on risks the client can change or control.

G. Coronary artery disease: Although not modifiable in itself, many contributing factors to CAD—such as diet, activity level, and smoking—can be addressed. Risk factor management helps prevent complications and progression of vascular disease.

H. Tobacco use: Smoking is one of the strongest modifiable risk factors for aortic aneurysm development and rupture. Smoking cessation significantly decreases progression rates and improves overall vascular health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While transferring a client with a chest tube from the bed to a stretcher, the chest tube becomes disconnected from the water- seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. Which action should the nurse implement next?

Correct Answer is A

Explanation

Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.

Correct Answer is ["B","C","D","G","H"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.