Question

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

Answer 1

Correct Answers:

Tinnitus

Rationale :

💊 Tinnitus is an adverse effect of cisplatin because this medication can cause ototoxicity, damaging the structures of the inner ear.

💊 Cisplatin is a platinum-based chemotherapy medication commonly used to treat cancers such as lung cancer.

💊 Ototoxic effects may include tinnitus (ringing in the ears), hearing loss, and difficulty hearing high-frequency sounds.

💊 The nurse should assess the client’s baseline hearing status and monitor for new hearing changes during treatment.

💊 Cisplatin can also cause nephrotoxicity, so kidney function and hydration status should be monitored closely.

💊 This answer is correct because tinnitus is a classic dose-limiting adverse effect of cisplatin therapy.

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Answer 2

Correct Answers:

The nurse auscultates coarse crackles in the lung fields

Rationale :

🫁 Coarse crackles in the lung fields indicate that the client has retained airway secretions, which is a reason to suction a tracheostomy.

🫁 Coarse crackles occur when air moves through thick mucus or secretions in the larger airways.

🫁 A tracheostomy bypasses the upper airway, reducing normal humidification and filtration, which can lead to increased secretion production and mucus accumulation.

🫁 Suctioning helps remove obstructing secretions, improve airway patency, and promote effective oxygenation.

🫁 The nurse should suction only when indicated, because unnecessary suctioning can cause airway trauma, hypoxia, and increased irritation.

🫁 This answer is correct because coarse crackles are a clinical sign of retained secretions requiring airway clearance.

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Answer 3

Correct Answers:

Total lung capacity

Rationale :

🫁 Total lung capacity (TLC) is the volume of air the lungs can hold at the end of maximum inhalation.

🫁 TLC represents the maximum amount of air contained in the lungs after taking the deepest possible breath.

🫁 It is calculated by adding the vital capacity (VC) and the residual volume (RV).

🫁 Pulmonary function tests use TLC to evaluate overall lung size and identify conditions such as restrictive lung diseases, where lung expansion is reduced.

🫁 A decreased TLC may occur with conditions such as pulmonary fibrosis, while an increased TLC may occur with some obstructive diseases.

🫁 This answer is correct because TLC measures the maximum volume of air present in the lungs after maximal inspiration.

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Answer 4

Correct Answers:

"You must return to the clinic to have the test read in 2 or 3 days."

Rationale :

🦠 The client must return to the clinic 48 to 72 hours (2 to 3 days) after placement of the tuberculin skin test (TST) so the nurse can assess for induration (firm swelling).

🦠 The reaction cannot be accurately interpreted immediately after administration because the immune response develops over time.

🦠 The nurse measures the diameter of induration, not redness, to determine whether the test is positive.

🦠 Failure to return within the appropriate time frame may require repeating the test because the result may no longer be accurate.

🦠 This answer is correct because the most important teaching point is that the client must return for proper interpretation of the test.

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Answer 5

Correct Answers:

Eat high-calorie foods first

Rationale :

🫁 Eating high-calorie foods first is recommended for a client with COPD and malnutrition because fatigue and shortness of breath may limit how much the client can eat during meals.

🫁 Clients with COPD often have increased energy demands due to the increased work of breathing.

🫁 Eating the most nutrient-dense and calorie-rich foods when appetite and energy are highest helps maximize nutritional intake.

🫁 Smaller, more frequent meals with high-calorie and high-protein foods are commonly recommended to prevent weight loss and muscle wasting.

🫁 Improving nutritional status helps strengthen respiratory muscles and supports overall recovery.

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Answer 6

Correct Answers:

Dry cough

Rationale :

🦠 Dry cough is an expected finding during the prodromal stage of inhalation anthrax because the infection initially affects the respiratory system after inhalation of Bacillus anthracis spores.

🦠 The prodromal phase usually presents with nonspecific, flu-like symptoms including fever, fatigue, malaise, mild cough, and chest discomfort.

🦠 After the prodromal phase, inhalation anthrax can rapidly progress to a severe stage with respiratory distress, mediastinal widening, shock, and respiratory failure.

🦠 Early recognition of respiratory symptoms after possible anthrax exposure is important because treatment is most effective when started early.

🦠 This answer is correct because a dry cough is a classic early respiratory manifestation of inhalation anthrax.

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Answer 7

Correct Answers:

Night sweats

Rationale :

🦠 Night sweats are a classic clinical manifestation of pulmonary tuberculosis (TB) due to the body’s immune response to Mycobacterium tuberculosis infection.

🦠 Pulmonary TB commonly presents with persistent cough, fever, night sweats, fatigue, weight loss, and sometimes hemoptysis (coughing blood).

🦠 Night sweats occur because the immune system releases inflammatory substances while fighting the infection, causing temperature regulation changes during sleep.

🦠 A client with recent TB exposure should be assessed for these symptoms and tested appropriately to determine whether infection is present.

🦠 This answer is correct because night sweats are a hallmark systemic manifestation of active pulmonary tuberculosis.

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Answer 8

Correct Answers:

Promotes carbon dioxide elimination

Rationale :

🫁 Pursed-lip breathing promotes carbon dioxide elimination because it creates resistance during exhalation, helping keep small airways open longer.

🫁 Clients with emphysema have damaged alveoli and airway collapse during expiration, causing air trapping and difficulty removing carbon dioxide.

🫁 Breathing in through the nose and slowly exhaling through pursed lips increases airway pressure, preventing premature airway closure.

🫁 This technique allows more complete exhalation, reduces trapped air, and improves ventilation efficiency.

🫁 It also decreases the work of breathing and can reduce feelings of shortness of breath.

🫁 This answer is correct because pursed-lip breathing improves expiration and helps remove retained carbon dioxide in COPD.

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Answer 9

Correct Answers:

Sitting while leaning forward over the bedside table

Rationale :

🫁 Sitting while leaning forward over the bedside table is the recommended position for a thoracentesis because it allows the spaces between the ribs to widen and provides better access to the pleural space.

🫁 This position helps the client remain stable while the provider inserts the needle into the pleural cavity to remove fluid or air.

🫁 Leaning forward also promotes maximum lung expansion and improves visualization of the affected area.

🫁 Thoracentesis is commonly performed to diagnose or treat pleural effusion, where excess fluid accumulates between the lung and chest wall.

🫁 The nurse should assist the client into this position and encourage them to remain still during the procedure to reduce the risk of injury.

🫁 This answer is correct because the upright leaning-forward position provides optimal access to the pleural space.

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Answer 10

Correct Answers:

Absence of breath sounds

Rationale :

🫁 Absence of breath sounds is an expected manifestation of a pneumothorax because air accumulates in the pleural space and prevents normal lung expansion on the affected side.

🫁 In a closed pneumothorax, air enters the pleural cavity without an external chest wound, causing the lung to collapse partially or completely.

🫁 The collapsed lung cannot effectively transmit normal breath sounds to the chest wall, resulting in decreased or absent breath sounds on the affected side.

🫁 Other findings may include sudden sharp chest pain, dyspnea, tachypnea, tachycardia, and decreased oxygen saturation.

🫁 Following trauma, such as a motor vehicle crash with chest bruising, the nurse should recognize the risk for pneumothorax and assess respiratory status immediately.

🫁 This answer is correct because air in the pleural space causes decreased ventilation and absent breath sounds on the affected side.

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QLexNursing

1 :
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

2 :
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

3 :
A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

4 :
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

5 :
A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

6 :
A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

7 :
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

8 :
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following?

9 :
A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client?

QLexNursing

1 : A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

2 : A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

3 : A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

4 : A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

5 : A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

6 : A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

7 : A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

8 : A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following?

9 : A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client?

1 :
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

2 :
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

3 :
A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

4 :
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

5 :
A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

6 :
A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

7 :
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

8 :
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following?

9 :
A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client?