Nokea
A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?
- A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
- B. ''I need to avoid drinking fluids if I develop symptoms.''
- C. ''I need a flu shot every 2 years because of the different flu strains.''
- D. ''I should cover my mouth with my hand when I sneeze.''
Correct Answer: A
Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.
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A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?
- A. Non-rebreather mask
- B. Venturi mask
- C. Nasal cannula
- D. Simple face mask
Correct Answer: B
Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.
A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?
- A. Client who has dysphagia
- B. Client who has AIDS
- C. Client who was vaccinated for pneumococcus and influenza 6 months ago
- D. Client who has a closed head injury and is receiving ventilation
Correct Answer: C
Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.
A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?
- A. Antibiotic
- B. Beta-blocker
- C. Antiviral
- D. Beta2 agonist
Correct Answer: D
Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.
Prior to a thoracentesis, which of the following actions should the nurse take?
- A. Position the client in an upright position, leaning over the bedside table.
- B. Explain the procedure.
- C. Obtain ABGs.
- D. Administer benzocaine spray.
Correct Answer: A
Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.
A healthcare professional is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the professional recognize?
- A. Confusion
- B. Pale skin
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: Pale skin is an early manifestation of hypoxemia due to decreased oxygenation of the blood. The skin may appear pale as the body redirects blood flow to vital organs in response to low oxygen levels. Confusion, bradycardia, and hypotension may occur as hypoxemia worsens, but pale skin is one of the initial signs that healthcare professionals should recognize when assessing a client experiencing respiratory distress.