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A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
- A. You will not be able to eat or drink after the procedure until you are able to cough.
- B. You will need to take deep breaths through your nose during the procedure.
- C. The procedure is painful and sedation will not be used.
- D. You will need to stay on bed rest for 24 hours after the procedure.
Correct Answer: A
Rationale: Correct Answer: A: You will not be able to eat or drink after the procedure until you are able to cough.
Rationale: It is important for the client to know that they will not be able to eat or drink post-bronchoscopy until they can cough effectively to prevent aspiration. This instruction reduces the risk of complications such as aspiration pneumonia. The nurse should emphasize the importance of clearing secretions by coughing before resuming oral intake.
Summary of Incorrect Choices:
B: Taking deep breaths through the nose is not necessary during bronchoscopy; the procedure involves visualization of the airways, not breathing techniques.
C: Bronchoscopy is usually performed under sedation, and the client should be informed about the use of sedation to manage pain and discomfort.
D: Bed rest for 24 hours after bronchoscopy is unnecessary; the client can resume normal activities unless otherwise instructed by the healthcare provider.
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A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
- A. Sweating
- B. Increased thirst
- C. Shakiness
- D. Decreased urination
Correct Answer: B
Rationale: Correct Answer: B - Increased thirst
Rationale: Hyperglycemia results in elevated blood glucose levels, which leads to osmotic diuresis and fluid loss, causing increased thirst. Sweating (A) is more commonly associated with hypoglycemia. Shakiness (C) is a symptom of hypoglycemia due to low blood sugar levels. Decreased urination (D) is not a typical manifestation of hyperglycemia as it is more commonly associated with conditions like dehydration or kidney issues.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
- A. Sinus bradycardia
- B. Atrial fibrillation
- C. Ventricular tachycardia
- D. First-degree heart block
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?
- A. Walk 30 min daily at a comfortable pace.
- B. Avoid all sources of dietary fat.
- C. Increase sodium intake to prevent dehydration.
- D. Only exercise if experiencing symptoms.
Correct Answer: A
Rationale: Correct Answer: A: Walk 30 min daily at a comfortable pace.
Rationale: Regular physical activity, such as walking, helps prevent coronary artery disease by improving cardiovascular health, maintaining a healthy weight, and reducing stress. Walking for 30 minutes daily at a comfortable pace can improve circulation, lower blood pressure, and reduce the risk of developing heart disease.
Summary of other choices:
B: Avoiding all sources of dietary fat is not recommended as the body needs healthy fats for various functions.
C: Increasing sodium intake does not prevent coronary artery disease and can actually contribute to hypertension, a risk factor for the disease.
D: Only exercising when experiencing symptoms is not proactive in preventing coronary artery disease and may lead to missed opportunities for prevention.
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
- A. Close the pinch clamp on the CVC.
- B. Administer oxygen via non-rebreather mask.
- C. Place the client in Trendelenburg position.
- D. Obtain emergency IV access.
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (D) is not the first priority in this situation; preventing air embolism is critical.