Nokea
A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
- B. ''I will lie on my back with my knees bent.''
- C. ''I will rest my hand over my abdomen to create resistance.''
- D. ''I will take in a deep breath and hold it before exhaling.''
Correct Answer: D
Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.
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A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
- A. This medication is given to treat infection.
- B. This medication is given to facilitate ventilation.
- C. This medication is given to decrease inflammation.
- D. This medication is given to reduce anxiety.
Correct Answer: B
Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.
A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?
- A. Bradypnea
- B. Pleural friction rub
- C. Petechiae
- D. Tachycardia
Correct Answer: A
Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.
A healthcare professional is reviewing the health records of five clients. Which of the following clients is not at risk for developing acute respiratory distress syndrome?
- A. A client who experienced a near-drowning incident
- B. A client following coronary artery bypass graft surgery
- C. A client who has a hemoglobin of 15.1 g/dL
- D. A client who has dysphagia
Correct Answer: C
Rationale: Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be triggered by various factors such as near-drowning incidents, surgeries like coronary artery bypass graft, and underlying conditions like dysphagia. Hemoglobin levels do not directly influence the risk of developing ARDS. A hemoglobin level of 15.1 g/dL falls within the normal range and does not predispose an individual to ARDS.
A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?
- A. Albuterol can increase my blood sugar levels.
- B. Albuterol can decrease my immune response.
- C. I can experience an increase in my heart rate while taking albuterol.
- D. I may develop mouth sores while taking albuterol.
Correct Answer: C
Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.
When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?
- A. Air should be instilled into the monitoring system after the procedure.
- B. The client should be positioned on the left side after the procedure.
- C. The transducer should be level with the second intercostal space after the line is placed.
- D. A chest x-ray is needed to verify placement after the procedure.
Correct Answer: D
Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.