Nokea
A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
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A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?
- A. Assess the client's blood pressure and level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Obtain a permit for an emergency temporary pacemaker insertion.
- D. Prepare to administer antidysrhythmic medication.
Correct Answer: A
Rationale: The correct action is to assess the client's blood pressure and level of consciousness. This is crucial in a client with an inferior wall MI to monitor for potential complications like cardiogenic shock. Assessing these vital signs can provide immediate information on the client's hemodynamic stability. Calling the health care provider or Rapid Response Team may be necessary based on assessment findings. Obtaining a permit for a temporary pacemaker insertion and preparing to administer antidysrhythmic medication are not the most immediate priorities and may not address the client's current needs.
Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do?
- A. Teach the patient controlled breathing
- B. Explain the rationale for these activities
- C. Provide adequate and regular pain medication
- D. Use an incentive spirometer to motivate the patient
Correct Answer: C
Rationale: Pain management enables patients to perform respiratory exercises effectively, preventing complications.
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:
- A. Pain.
- B. Impaired gas exchange.
- C. Decrease Cardiac output.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Impaired gas exchange is the main issue in pulmonary edema.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.
Why is caution needed when asking family members to interpret?
- A. Family members may misinterpret or omit critical information.
- B. It saves time and resources.
- C. It promotes family involvement.
- D. It ensures confidentiality.
Correct Answer: A
Rationale: Family members may unintentionally alter messages, leading to potential misunderstandings or errors in care.