The nurse assigns a client with lung cancer the nursing diagnosis of Activity Intolerance. Which
intervention should the nurse include in the care plan?
A) Discourage the client's family from providing assistance to the client.
B) Encourage the client to remain in bed as much as possible.
C) Plan care to cluster activities.
D) Keep frequently-used objects within the client's easy reach. D) Keep frequently-used
objects within the client's easy reach.
Rationale: Keeping frequently used objects within easy reach allows the client to conserve
energy. Family assistance should be encouraged. The maintenance of physical activity to the
level of tolerance should be encouraged. Nursing activities should be alternated with frequent
rest periods.
The nurse is caring for a client in a community clinic who wishes to quit smoking. The client asks
the nurse, "If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?"
A) "No one knows for sure what the risk is for someone who quits smoking."
B) "Your risk of lung cancer will be equal to that of a nonsmoker."
C) "Your risk of lung cancer will decline if you quit, but it will remain higher than a
nonsmoker's."
D) "Your risk of lung cancer will never drop because the damage has already be done." C)
"Your risk of lung cancer will decline if you quit, but it will remain higher than a non-smoker's."
Rationale:
While the client's risk for lung cancer will diminish sharply upon quitting smoking, it will not
drop to the level of someone who never smoked. The risk for someone who quits is known to
be dramatically less than for someone who continues to smoke. Another factor when
calculating risk is the client's exposure to secondhand smoke, which also increases risk.
The nurse is planning care to address ineffective airway clearance for a client with lung cancer.
Which interventions should the nurse include in the client's plan of care? SATA
A) Suction the airway as needed
, B) Help the client turn, cough and deep breathe as needed
C) Provide chest percussion as ordered
D) Educate the client about smoking cessation
E) Administer pneumococcal vaccine A, B, C
Rationale:
Turning, coughing, deep breathing, airway suctioning, and chest percussion can help clear
secretions and improve airway clearance. Administering the pneumococcal vaccine and
educating the client on smoking cessation are important in treating a client with lung cancer,
but they would be aligned with a different nursing diagnosis.
A nurse is caring for a client recovering from a wedge resection of the left lung for a tumor.
What would be appropriate goals for the nursing diagnosis of ineffective airway clearance?
SATA
A) Minimize accumulation of fluid
B) Participation in care by the client.
C) Maintain a patent airway
D) Maintain a current weight
E) Express feelings and concerns A, C
Rationale:
All of the outcomes for this client are viable, but appropriate outcomes for the diagnosis of
ineffective airway clearance are maintaining a patent airway and minimizing the accumulation
of fluid.
The nurse is caring for a client who is undergoing diagnostic tests to rule out lung cancer. The
client asks the nurse why a CT scan was ordered. What is the best response by the nurse?
A) "The doctor prefers this test."
B) "To rule out the possibility that your problems are caused by pneumonia."
C) "It's more specific in diagnosing your condition."
D) "What are you concerned about this test?" C) "It's more specific in diagnosing your
condition."