Nokea
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
- A. Assess for other manifestations of hypoxia
- B. Change the sensor on the pulse oximeter
- C. Obtain a new oximeter from central supply
- D. Tell the client to take slow, deep breaths
Correct Answer: A
Rationale: Pulse oximetry can sometimes produce normal readings despite hypoxia due to factors like poor peripheral perfusion. A thorough assessment for other signs of hypoxia (e.g., tachycardia, confusion) is the most appropriate action to confirm the client's status.
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A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes, PCO2: 28 mm Hg, Respiratory rate: 34, Feels frightened, PO2: 88 mm Hg, Can't catch my breath, SPO2: 88%, Blood pressure 158/92 mm Hg, Lungs have crackles. What action by the nurse is most appropriate?
- A. Call respiratory therapy for a breathing treatment
- B. Facilitate a STAT pulmonary angiography
- C. Prepare for immediate endotracheal intubation
- D. Prepare to administer intravenous anticoagulants
Correct Answer: B
Rationale: The client's symptoms and data (tachypnea, hypoxia, low PCO2, crackles, and anxiety) suggest a pulmonary embolism. STAT pulmonary angiography is the most appropriate action to confirm the diagnosis.
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?
- A. It will increase the motility of the gastrointestinal tract
- B. It will keep the gastrointestinal tract functioning normally
- C. It will prepare the gastrointestinal tract for enteral feedings
- D. It will prevent ulcers from the stress of mechanical ventilation
Correct Answer: D
Rationale: Ranitidine, a histamine blocker, is used prophylactically to prevent stress ulcers, which are common in mechanically ventilated clients due to physiological stress.
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
- A. Apply oxygen at 100%
- B. Assess the respiratory rate
- C. Ensure a patent airway
- D. Start two large-bore IV lines
Correct Answer: C
Rationale: For chest trauma, the priority follows the ABCs (airway, breathing, circulation). Ensuring a patent airway is the first step to stabilize the client.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
- A. Determine if the tube is kinked
- B. Ensure all connections are patent
- C. Listen to the client's lung sounds
- D. Suction the endotracheal tube
Correct Answer: C
Rationale: For an intubated client with hypoxia, the nurse should first assess for DOPE (displaced tube, obstruction, pneumothorax, equipment problems). Listening to lung sounds to confirm tube placement is the priority, as a displaced tube is the most common cause of hypoxia.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
- A. Hamburger and French fries
- B. Large chef's salad and muffin
- C. No selection, spouse brings pizza
- D. Tuna salad sandwich and chips
Correct Answer: B
Rationale: Warfarin inhibits vitamin K-dependent clotting factors. A large chef's salad with leafy greens high in vitamin K can interfere with warfarin's effectiveness, indicating a need for further education.