Nokea
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
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A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)
- A. administer antibiotics every 4 hrs
- B. Encourage the client to use the spirometer every 4 hours.
- C. Ensure the client wears TED hose or sequential compression devices.
- D. Have the client rate pain on a 0-to-10 scale and report to the nurse.
Correct Answer: C
Rationale: The correct answer is C because ensuring the client wears TED hose or sequential compression devices is within the scope of practice for UAP. This task does not require critical thinking or assessment skills, making it suitable for delegation. Administering antibiotics (A) and encouraging spirometer use (B) require clinical judgment and assessment skills, which UAP do not possess. Having the client rate pain and report to the nurse (D) involves subjective assessment and potential interventions, making it inappropriate for delegation to UAP.
A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?
- A. I will breathe in quickly through my mouth and out through my nose.
- B. I will breathe in slowly through my nose and out through pursed lips.
- C. I will hold my breath for 10 seconds before exhaling.
- D. I will breathe in and out through pursed lips.
Correct Answer: B
Rationale: The correct answer is B because pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips, which helps improve lung function and relaxes the client. Choice A is incorrect because breathing in quickly through the mouth is not part of pursed-lip breathing technique. Choice C is incorrect as holding breath before exhaling is not recommended in pursed-lip breathing. Choice D is partially correct but lacks the emphasis on inhaling slowly through the nose. Therefore, the most effective statement indicating correct teaching is choice B.
Mrs. Brown asks about the difference between wide- and narrow-angle glaucoma. Which of the following responses would be most appropriate?
- A. With wide-angle glaucoma there is a minimal increase in ocular pressure.
- B. Wide-angle glaucoma is usually asymptomatic.
- C. Complications from narrow-angle glaucoma are less severe than those from wide-angle glaucoma.
- D. Narrow-angle glaucoma is usually asymptomatic.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the primary advantage of the use of midazolam (Versed) as an adjunct to general anesthesia?
- A. Amnestic effect
- B. Analgesic effect
- C. Prolonged action
- D. Antiemetic effect
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is prescribed prednisone for asthma management. Which statement by the client indicates a need for further teaching?
- A. I will take this medication every day to prevent asthma attacks.
- B. I will avoid people with infections while taking this medication.
- C. I will take this medication with food to prevent stomach upset.
- D. I will stop taking this medication if I feel fine.
Correct Answer: D
Rationale: The correct answer is D because stopping prednisone abruptly can lead to adrenal insufficiency due to the suppression of the body's natural cortisol production. The client should never stop taking prednisone suddenly without consulting the healthcare provider. Choice A is correct because prednisone is often used as a daily preventive medication for asthma. Choice B is correct as prednisone can lower the immune system, making the client more susceptible to infections. Choice C is incorrect because prednisone is usually taken with food to minimize stomach upset.