Nokea
A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
- A. It produces greater blood oxygen levels.
- B. It is easier to breathe through the nose.
- C. The nares humidify, warm, and filter the air.
- D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Correct Answer: C
Rationale: The nares humidify, warm, and filter air, improving its quality for respiration.
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The nurse knows that the correct way to position the hands when performing the abdominal thrust maneuver is with the thumb side of the closed fist on which part of the victim's abdomen?
- A. Directly on the manubrium
- B. Above the xiphoid process
- C. Below the navel
- D. Below the sternum
Correct Answer: B
Rationale: Positioning the fist above the xiphoid process (below the sternum) ensures safe and effective abdominal thrusts to dislodge the obstruction.
The nurse knows to discontinue the client's sponge bath if the client develops which symptom?
- A. Nausea
- B. Chills
- C. Flushing
- D. Confusion
Correct Answer: B
Rationale: Chills during a sponge bath indicate the client is becoming too cold, which can worsen discomfort and should prompt discontinuation.
You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately?
- A. I'm seeing yellow halos around the light.'
- B. My mouth tastes like metal.'
- C. My head hurts.'
- D. I have this constant ringing in my ears.'
Correct Answer: D
Rationale: Ringing in the ears indicates potential ototoxicity, a serious vancomycin side effect requiring immediate cessation and physician notification. Other symptoms (A, B, C) are less specific and not immediately alarming.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.