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The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
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The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these describes the normal pathway?
- A. AV node, SA node, Bundle of His, Purkinje fibers
- B. Purkinje fibers, SA node, AV node, Bundle of His
- C. Bundle of His, Purkinje fibers, SA node
- D. SA node, AV node, Bundle of His, Purkinje fibers
Correct Answer: D
Rationale: SA node, AV node, Bundle of His, Purkinje fibers. This is the normal pathway of an electrical impulse through the heart.
The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
The best position for the client with a right total hip replacement is:
- A. With the right hip flexed 90°
- B. With the right hip flexed 35°
- C. Supine with pillows supporting the right leg
- D. Sims position with the right leg adducted
Correct Answer: C
Rationale: Supine with pillows supporting the leg prevents dislocation while maintaining alignment. Flexion or adduction risks complications.
The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive 'medicine under the skin,' and the client is visibly anxious. Which nursing intervention is appropriate?
- A. Ask the child to count to 10 during injection
- B. Ask the parent to hold the child's arms tightly
- C. Explain to the child that the injection will not hurt
- D. Keep the injection needle out of the child's view
Correct Answer: D
Rationale: Hiding the needle (D) reduces anxiety. Counting (A) may not distract enough, holding arms (B) can increase fear, and denying pain (C) is dishonest.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.