Nokea
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client does not appear to be moving normally with respirations, oxygen saturation is 92%. What action by the nurse is best?
- A. Administer oxygen via non-rebreather mask
- B. Perform a rapid trauma assessment
- C. Prepare for chest tube insertion
- D. Obtain a chest X-ray immediately
Correct Answer: A
Rationale: The client's abnormal respiratory movement and low oxygen saturation suggest a traumatic chest injury, possibly pneumothorax or hemothorax. Administering oxygen via a non-rebreather mask is the priority to address hypoxia while further assessment is conducted.
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A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
- A. Assessing that the ventilator settings are correct
- B. Ensuring there is a bag-valve-mask in the room
- C. Obtaining personal protective equipment
- D. Planning to suction the client upon arrival to the room
Correct Answer: B
Rationale: A bag-valve-mask is critical for manual ventilation in case of ventilator failure, making it the priority to ensure client safety.
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes, PCO2: 28 mm Hg, Respiratory rate: 34, Feels frightened, PO2: 88 mm Hg, Can't catch my breath, SPO2: 88%, Blood pressure 158/92 mm Hg, Lungs have crackles. What action by the nurse is most appropriate?
- A. Call respiratory therapy for a breathing treatment
- B. Facilitate a STAT pulmonary angiography
- C. Prepare for immediate endotracheal intubation
- D. Prepare to administer intravenous anticoagulants
Correct Answer: B
Rationale: The client's symptoms and data (tachypnea, hypoxia, low PCO2, crackles, and anxiety) suggest a pulmonary embolism. STAT pulmonary angiography is the most appropriate action to confirm the diagnosis.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
- A. Adherence to proper hand hygiene
- B. Administering anti-ulcer medication
- C. Elevating the head of the bed
- D. Providing oral care per protocol
- E. Suctioning the client on a regular schedule
Correct Answer: A,B,C,D
Rationale: The ventilator bundle to prevent ventilator-associated pneumonia includes hand hygiene, anti-ulcer medications, elevating the head of the bed (30"?45 degrees), and frequent oral care. Suctioning is performed as needed, not on a fixed schedule.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
- A. Alteplase (Activase)
- B. Enoxaparin (Lovenox)
- C. Unfractionated heparin
- D. Warfarin sodium (Coumadin)
Correct Answer: A
Rationale: Alteplase is a thrombolytic indicated for large pulmonary embolisms with hemodynamic instability to rapidly dissolve the clot and restore circulation.