Question

A patient with active TB is prescribed rifampin. Which nursing consideration is most important to include in patient teaching?

Answer 1

Correct Answers:

Avoid alcoholic beverages to prevent liver toxicity

Rationale :

🟠 Rifampin is hepatotoxic, and combining it with alcohol significantly increases the risk of liver damage, making alcohol avoidance essential.

🟠 The medication already places stress on hepatic enzymes, so eliminating additional hepatotoxic substances protects long-term liver function.

🟠 Clients must also be taught that rifampin causes orange body fluids, but liver safety is the top priority to prevent irreversible harm.

🟠 Careful monitoring of AST/ALT is also required due to this increased risk.

❌ — Rifampin decreases oral contraceptive effectiveness.

❌ — Vision changes relate to ethambutol, not rifampin.

❌ — TB therapy requires strict, daily scheduled dosing.

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Answer 2

Correct Answers:

Nasal cannula at 2-4 L/min

Rationale :

🟩 Patients with chronic hypercarbia (e.g., COPD) require low-flow oxygen to avoid suppressing their hypoxic drive to breathe.

🟩 A nasal cannula at 2–4 L/min provides enough oxygen to maintain saturations >90% without causing dangerous CO₂ retention.

🟩 High-flow devices (simple masks, NRBs, partial rebreathers) deliver too much oxygen and risk worsening hypercapnia.

🟩 Controlled, titrated oxygen is the safest method for stabilizing this population.

❌ A/B/C — All deliver high oxygen concentrations → dangerous CO₂ narcosis risk.

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Answer 3

Correct Answers:

Assess how often the patient is swallowing

Rationale :

🔵 Frequent swallowing after rhinoplasty may indicate posterior nasal bleeding, which is a potentially serious, hidden complication.

🔵 Bleeding can drip down the throat rather than appear externally, so swallowing frequency becomes a key early indicator.

🔵 Identifying internal bleeding early prevents airway compromise and hemorrhagic shock.

🔵 This assessment is more urgent than swelling, hydration, or nose-blowing instruction.

❌ — Fluid intake is helpful but not a priority for detecting complications.

❌ — Teaching is important but not the priority assessment.

❌ — Expected postoperative finding, not early warning of complications.

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Answer 4

Correct Answers:

Determine whether the cough started after beginning the ACE inhibitor

Rationale :

💠 ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation.

💠 Identifying the timing of symptom onset helps confirm whether the medication is the likely cause.

💠 This guides whether the provider should switch to an ARB such as losartan.

💠 Assessing before assuming infection or recommending OTC remedies ensures safe practice.

❌ Document the cough as a likely respiratory infection— Incorrect assumption; must assess first.

❌ Recommend over-the-counter cough suppressants for symptom relief — OTC suppressants do not address the cause and may be unsafe.

❌ Ask whether the patient uses any inhaled Illicit substances — Illicit inhalants do not match the classic ACE-inhibitor cough pattern.

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Answer 5

Correct Answers:

Distended neck veins and dependent edema

Rationale :

🟣 Chronic bronchitis can progress to cor pulmonale, where right-sided heart failure develops due to chronic pulmonary hypertension.

🟣 Right-sided failure leads to systemic venous congestion, presenting with JVD and peripheral edema.

🟣 These findings indicate a serious cardiovascular complication, not merely worsening COPD symptoms.

🟣 Early recognition prevents further decompensation and guides appropriate therapy.

❌ Productive cough with thick mucus— Expected COPD symptom, not heart failure.

❌ Use of accessory muscles during respiration — Reflects respiratory effort, not HF.

❌Dyspnea worsening with exertion — Common in COPD, non-specific.

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Answer 6

Correct Answers:

Ask about current and past workplace exposures to particulate matter

Rationale :

🟤 The I PREPARE model begins with evaluating environmental exposures, making occupational assessment the first step.

🟤 As a baker, the patient may inhale flour dust, spores, or particulate matter that worsen chronic respiratory symptoms.

🟤 Identifying workplace triggers guides the need for masks, ventilation adjustments, or referral to occupational medicine.

🟤 This step also helps differentiate COPD from occupational lung diseases such as baker’s asthma.

❌ Ask whether she has traveled recently to areas where fungal lung diseases are common— Travel exposure is not the first step.

❌ Ask whether her sputum has a foul odor or rust color— Assesses infection but not environmental history.

❌ Ask whether her dyspnea is relieved by sitting upright— Identifies orthopnea, not exposure risks.

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Answer 7

Correct Answers:

Use wire cutters to remove fixation during choking or vomiting

Rationale :

🟥 After inner maxillary fixation (IMF), the mouth is wired shut, making airway obstruction during choking or vomiting a life-threatening emergency.

🟥 Wire cutters must be kept with the patient at all times so fixation wires can be removed instantly if aspiration risk occurs.

🟥 Educating the patient on emergency release procedures prevents suffocation and is the most critical safety teaching.

🟥 Other postoperative care matters, but airway protection supersedes all.

❌ Avoid speaking for the first 24 hours postoperatively — Speaking restrictions do not prevent emergencies.

❌ Perform oral irrigation with antiseptic mouthwash three times daily— Oral care is important but not life-saving.

❌ Increase fluid intake to promote hydration — Hydration is helpful, not critical for emergency survival.

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Answer 8

Correct Answers:

Monitoring for signs of increased intracranial pressure and airway compromise.

Rationale :

🟣 Superior vena cava syndrome obstructs venous return from the head, neck, and upper body, causing venous congestion, edema, and rising pressure.

🟣 This congestion can rapidly progress to airway obstruction, facial swelling, stridor, and respiratory collapse.

🟣 It may also lead to increased intracranial pressure (ICP) due to impaired drainage from the brain, resulting in headaches, confusion, or decreased LOC.

🟣 Early detection of respiratory or neurological compromise is the nurse’s highest priority because these are life-threatening complications.

❌Limiting fluid Intake to reduce edema.— Fluid restriction does not resolve venous obstruction.

❌ Teaching the patient that SVCS is a minor complication of lung cancer.— SVCS is a medical emergency, not minor.

❌ Encouraging ambulation to improve venous return. — Ambulation does not relieve vena cava obstruction.

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Answer 9

Correct Answers:

Request an order for endotracheal intubation

Rationale :

🔴 Facial burns and increasing laryngeal edema signal impending airway obstruction, which can progress very rapidly.

🔴 Intubation should be performed early, before swelling makes the airway impossible to access safely.

🔴 The nurse must recognize the emergency and advocate for immediate intubation to secure the airway.

🔴 Delayed action risks total obstruction and inability to oxygenate or ventilate the patient.

❌Prepare for nasopharyngeal suctioning— Suctioning does not relieve airway swelling.

❌Encourage oral fluids to thin secretions — Fluids cannot prevent airway closure.

❌ Monitor oxygen saturation every hour — Hourly SpO₂ checks delay life-saving intervention.

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Answer 10

Correct Answers:

It allows documentation and pacing of activities based on patient-reported breathing difficulty.

Rationale :

🟢 The Visual Analog Dyspnea Scale (VADS) captures subjective dyspnea severity, reflecting how the patient perceives their breathing limitations.

🟢 COPD symptoms fluctuate, so patient-reported scoring helps guide activity pacing, rest intervals, and nursing workload planning.

🟢 It supports individualized care and tracks response to interventions such as bronchodilators or breathing techniques.

🟢 VADS supplements objective measurements by adding the patient's real-time experience of breathing effort.

❌ It replaces the need for arterial blood gas monitoring. — VADS does not replace ABGs.

❌It determines the appropriate oxygen flow rate for the patient. — Does not determine oxygen flow rate.

❌It predicts the likelihood of respiratory infection.— Does not predict infections.

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EXAMPLIFY NUR 105 EXAM 3 FALL 2025

No.

1 :
A patient with active TB is prescribed rifampin. Which nursing consideration is most important to include in patient teaching?

2 :
A patient with chronic hypercarbia is receiving oxygen therapy for hypoxemia. The nurse adjusts the oxygen flow to maintain an oxygen saturation greater than 90% while avoiding complications from excessive FiO.. Which oxygen delivery system is most appropriate for this patient at this time?

3 :
A nurse is caring for a patient who is postoperative day one following a rhinoplasty. Which nursing intervention takes priority in identifying a potential complication?

4 :
A patient reports a persistent dry cough that began several weeks ago. The nurse reviews the medication list and notes the patient is taking an ACE inhibitor for hypertension. Which nursing action is most appropriate?

5 :
When assessing a patient with chronic bronchitis, which clinical sign best indicates a complication related to right-sided heart failure?

7 :
The nurse is caring for a patient with inner maxillary fixation (IMF) following a jaw fracture repair. Which teaching point is most essential to prevent a life- threatening complication?

8 :
The nurse plans care for a patient with superior vena cava syndrome (SVCS) secondary to lung cancer. What should the nurse prioritize?

9 :
A nurse is caring for a hospitalized patient who has severe facial burns and signs of increasing laryngeal edema. Which intervention is most appropriate to anticipate and advocate for to prevent total airway obstruction?

10 :
How does assessing dyspnea with a Visual Analog Dyspnea Scale (VADS) support nursing care in COPD patients?

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EXAMPLIFY NUR 105 EXAM 3 FALL 2025

No.

1 : A patient with active TB is prescribed rifampin. Which nursing consideration is most important to include in patient teaching?

2 : A patient with chronic hypercarbia is receiving oxygen therapy for hypoxemia. The nurse adjusts the oxygen flow to maintain an oxygen saturation greater than 90% while avoiding complications from excessive FiO.. Which oxygen delivery system is most appropriate for this patient at this time?

3 : A nurse is caring for a patient who is postoperative day one following a rhinoplasty. Which nursing intervention takes priority in identifying a potential complication?

4 : A patient reports a persistent dry cough that began several weeks ago. The nurse reviews the medication list and notes the patient is taking an ACE inhibitor for hypertension. Which nursing action is most appropriate?

5 : When assessing a patient with chronic bronchitis, which clinical sign best indicates a complication related to right-sided heart failure?

7 : The nurse is caring for a patient with inner maxillary fixation (IMF) following a jaw fracture repair. Which teaching point is most essential to prevent a life- threatening complication?

8 : The nurse plans care for a patient with superior vena cava syndrome (SVCS) secondary to lung cancer. What should the nurse prioritize?

9 : A nurse is caring for a hospitalized patient who has severe facial burns and signs of increasing laryngeal edema. Which intervention is most appropriate to anticipate and advocate for to prevent total airway obstruction?

10 : How does assessing dyspnea with a Visual Analog Dyspnea Scale (VADS) support nursing care in COPD patients?

1 :
A patient with active TB is prescribed rifampin. Which nursing consideration is most important to include in patient teaching?

2 :
A patient with chronic hypercarbia is receiving oxygen therapy for hypoxemia. The nurse adjusts the oxygen flow to maintain an oxygen saturation greater than 90% while avoiding complications from excessive FiO.. Which oxygen delivery system is most appropriate for this patient at this time?

3 :
A nurse is caring for a patient who is postoperative day one following a rhinoplasty. Which nursing intervention takes priority in identifying a potential complication?

4 :
A patient reports a persistent dry cough that began several weeks ago. The nurse reviews the medication list and notes the patient is taking an ACE inhibitor for hypertension. Which nursing action is most appropriate?

5 :
When assessing a patient with chronic bronchitis, which clinical sign best indicates a complication related to right-sided heart failure?

7 :
The nurse is caring for a patient with inner maxillary fixation (IMF) following a jaw fracture repair. Which teaching point is most essential to prevent a life- threatening complication?

8 :
The nurse plans care for a patient with superior vena cava syndrome (SVCS) secondary to lung cancer. What should the nurse prioritize?

9 :
A nurse is caring for a hospitalized patient who has severe facial burns and signs of increasing laryngeal edema. Which intervention is most appropriate to anticipate and advocate for to prevent total airway obstruction?

10 :
How does assessing dyspnea with a Visual Analog Dyspnea Scale (VADS) support nursing care in COPD patients?