Nokea
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
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The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Document the second reading in the client record.
- C. Securely place the prongs of the cannula in the nostrils.
- D. Place the pulse oximeter on the client's earlobe.
Correct Answer: C
Rationale: Proper cannula placement ensures effective oxygen delivery.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
- A. Consult the palliative care team about the client's care.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Obtain a 'do not resuscitate' (DNR) prescription.
Correct Answer: C
Rationale: Clarifying 'heroic measures' ensures client wishes are understood.
History and physical
The client is a 69-year-old male with a history of emphysema and hypertension. He presented to the emergency room with shortness of breath and reporting chest pain. He was admitted to the medical floor for cardiac exam and monitoring.
Nurses notes :
1930
The client was alert and oriented when he first came on the unit. Now the client is confused and asking where he is at. His oxygen mask was found on the floor. His lips are blue.
Vital signs
. Heart rate 100 beats/minute
Respiratory rate 29 breaths/minute
. Blood pressure 155/89 mm Hg
Oxygen saturation 75% on room air
Orders:
1845
Admit to medical floor
. Clear liquid diet
12-lead electrocardiogram (ECG)
Apply oxygen 10 L/minute non-rebreather, titrate to keep oxygen saturation greater than 88%
.Send specimens to the laboratory for a blood gas, cardiac enzymes, chemistry, and complete blood count.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Replace the non rebreather mask;Perform oropharyngeal suctioning;Change the oxygen delivery method;Increase the flow of oxygen to 12L;Use a manual resuscitation bag to provide breaths
- B. Obstructed airway;Hypoxia;Pulmonary edema;Apnea
- C. Color and consistency of mucus;Oxygen saturation;Level of consciousness;Skin color;Gag reflex
Correct Answer:
Rationale: Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
- A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
- B. Assist the client in assuming a lateral recumbent position for comfort.
- C. Initiate continuous passive motion (CPM) to relieve muscle spasms.
- D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.
Correct Answer: A
Rationale: PCA pump allows self-administered analgesia for immediate pain relief.
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
- A. Ask an unlicensed assistive personnel to stay with the client.
- B. Place the bedpan within the reach of the client.
- C. Obtain a bedside commode for the client to use.
- D. Notify the healthcare provider of the client's concerns.
Correct Answer: C
Rationale: Commode prevents enema expulsion accidents.