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A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
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8. What is acupuncture used for (select all that apply)?
- A. Relieve pain by causing counterirritation in another area of the body.
- B. Reestablish the flow of Qi through meridians to simulate the body’s self-healing mechanism.
- C. Create an inflammatory response at an acupoint, increasing blood circulation and healing energy.
- D. Relieve nausea and vomiting postoperatively, with pregnancy, or related to chemotherapy.
Correct Answer: B
Rationale: Acupuncture is commonly used to reestablish the flow of Qi (option B) and relieve nausea and vomiting (option D), among other therapeutic uses.
How would the nurse describe the techniques used in energy medicine?
- A. Energy medicine involves manipulating energy fields through touch or intention.
- B. Energy medicine focuses on herbal supplements and probiotics.
- C. Energy medicine relies on mechanical devices for healing.
- D. Energy medicine is synonymous with allopathic medicine.
Correct Answer: A
Rationale: Energy medicine encompasses techniques like Reiki and acupuncture, targeting energy fields for healing purposes.
A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?
- A. 300 mL
- B. 480 mL
- C. 800 mL
- D. 950 mL
Correct Answer: B
Rationale: The correct answer is B: 480 mL. For a client with an ideal weight of 60 kg, the tidal volume should be set at 6-8 mL/kg of ideal body weight. Therefore, for a 60 kg individual, the tidal volume should be between 360-480 mL. B falls within this range and is the most appropriate choice.
A: 300 mL is too low and would not provide adequate ventilation for a client of this weight.
C: 800 mL is too high and could lead to overventilation and potential lung injury.
D: 950 mL is also too high and poses the same risks as option C.
In summary, B is the correct choice as it falls within the appropriate tidal volume range based on the client's ideal weight, while the other options are either too low or too high.
Mrs. Smith asks about treatment options for sensorineural deafness. To counsel Mrs. Smith appropriately, the nurse knows that the only type of organically caused deafness that can be effectively treated at this time is
- A. conductive deafness
- B. sensorineural deafness
- C. central deafness
- D. mixed-type deafness
Correct Answer: A
Rationale: Conductive deafness often responds well to surgical or medical interventions, unlike other types of hearing loss where treatment options are limited.
A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after 90 minutes, now reports severe incisional pain. The patient's blood pressure is 170/90 mmHg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to
- A. medicate the patient for pain.
- B. place the patient in a high Fowler position and administer oxygen.
- C. place the patient in a reverse Trendelenburg position and open the IV line.
- D. report the findings to the provider.
Correct Answer: D
Rationale: The nurse should report these findings to the provider because the patient may be experiencing complications such as hypertension or hypovolemia.