A patient with lung cancer confides in the nurse, expressing fear about the disease and guilt for smoking in the past. Which response from the nurse would be most appropriate?

“Don’t be too hard on yourself. It’s uncertain if your smoking led to the cancer.”.

“It’s normal to feel scared. What aspects of cancer frighten you the most?”

“Do you feel guilty because you used to smoke?”

“Fear is a normal reaction. We are here to support you through this.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Implementing ventilator-weaning protocols is a crucial intervention in the care plan for a patient on a ventilator to prevent ventilator-associated pneumonia. These protocols aim to minimize the patient’s exposure to mechanical ventilation, which is a significant risk factor for developing ventilator-associated pneumonia. By systematically reducing the level of ventilatory support, these protocols facilitate the earliest possible liberation from mechanical ventilation, thereby reducing the risk of ventilator-associated pneumonia.
Choice B rationale
Providing frequent oral care is another essential intervention in preventing ventilator- associated pneumonia. Oral health can quickly deteriorate in mechanically ventilated patients, leading to an increased risk of ventilator-associated pneumonia. Regular oral care, including the use of antiseptics, can help reduce the number of potential respiratory pathogens in the oral cavity and prevent their aspiration into the lower respiratory tract.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a standard intervention to prevent ventilator-associated pneumonia. Over-suctioning can lead to trauma and inflammation in the airway, potentially increasing the risk of infection. Suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Choice D rationale
Positioning the patient in a semi-upright position (30 to 45 degrees), rather than a prone position, is recommended to prevent ventilator-associated pneumonia. This position helps to reduce the risk of aspiration, which is a major risk factor for ventilator-associated pneumonia.
Choice E rationale
Avoiding suctioning the patient is not a recommended strategy for preventing ventilator- associated pneumonia. Suctioning is necessary to clear secretions from the airway, and its omission could potentially increase the risk of infection. However, as mentioned earlier, suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.

A. Muffled heart sounds. B. Sudden hemoptysis. C. Absent breath sounds on the affected side. D. Declining respiratory rate.

Correct Answer is C

Explanation

Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.

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A patient with lung cancer confides in the nurse, expressing fear about the disease and guilt for smoking in the past. Which response from the nurse would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

During a central IV line insertion at the bedside, a client reports shortness of breath and becomes tachypneic. Which finding should a nurse suspect indicates the client developed a pneumothorax?

Correct Answer is C

Explanation

A patient is being treated for bacterial pharyngitis. Which of the following should a nurse recommend to promote the patient’s nutrition during treatment?

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) who is being evaluated for a lung transplant. What findings should a nurse expect when performing an initial physical assessment on a client diagnosed with COPD? Select all that apply.

A nurse is preparing to administer cefaclor 500 mg PO every 12 hours. If the available cefaclor oral suspension is 250 mg/5 mL, how many mL should the nurse administer per dose?

A nurse is reviewing the arterial blood gas (ABG) results for a patient diagnosed with progressive Chronic Obstructive Pulmonary Disease (COPD). Which ABG results should the nurse expect for a patient with progressive COPD?

A nurse on a quality control committee is evaluating the effectiveness of recently implemented measures aimed at reducing medication errors. Which methods should the nurse use to evaluate the success of the changes?

A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

A nurse is caring for a client diagnosed with acute rhinosinusitis. Which of the following instructions should the nurse provide to the client? Select all that apply.

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?