Nokea
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should:
- A. Increase the oxygen flow rate from 2 to 4 L/minute.
- B. Call the physician immediately.
- C. Provide reassurance to the client.
- D. Obtain a sample for arterial blood gas analysis.
Correct Answer: A
Rationale: Increasing oxygen flow within the ordered range addresses increasing dyspnea and maintains oxygenation, which is the priority in suspected pulmonary embolism.
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Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
- A. Ask the client if she desires an epidural anesthetic.
- B. Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia.
- C. Tell the client that her labor will be more comfortable with an anesthetic.
- D. Ask the client to discuss this with her husband and then make a decision.
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
- A. What happened between you and your child?'
- B. Why is your child screaming?'
- C. Did something cause your child to be upset?'
- D. Have you tried to calm down your child?'
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
- A. Infection
- B. Pneumothorax
- C. Aspiration
- D. Dyspnea
Correct Answer: B
Rationale: Pneumothorax is a potential complication of thoracentesis due to the risk of lung puncture during the procedure, requiring immediate monitoring.
The nurse is teaching a client with a new tracheostomy about home care. Which of the following instructions should be included? Select all that apply.
- A. Clean the tracheostomy site daily.
- B. Suction the tracheostomy as needed.
- C. Change the tracheostomy tube monthly.
- D. Keep a spare tracheostomy tube at home.
- E. Use a humidifier to keep secretions thin.
Correct Answer: A, B, D, E
Rationale: Daily cleaning, suctioning, keeping a spare tube, and using a humidifier are essential for tracheostomy care. Tube changes are typically done by professionals.