Nokea
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Preoxygenate the client with 100% oxygen for up to 3 min.
- B. Perform suctioning for no longer than 30 seconds.
- C. Apply suction while inserting the catheter.
- D. Limit oxygen therapy to 50% prior to suctioning.
Correct Answer: A
Rationale: The correct answer is A: Preoxygenate the client with 100% oxygen for up to 3 min. This is essential to prevent hypoxemia during the suctioning procedure. Adequate preoxygenation helps to increase the oxygen reserves in the client's lungs, reducing the risk of oxygen desaturation during and after suctioning. This is particularly important for clients with COPD and an artificial airway, as they are already at risk for hypoxemia due to impaired lung function.
Choices B, C, and D are incorrect:
B: Performing suctioning for no longer than 30 seconds is a general guideline, but it is not specific to clients with COPD and an artificial airway.
C: Applying suction while inserting the catheter is incorrect as this can cause trauma to the airway and increase the risk of infection.
D: Limiting oxygen therapy to 50% prior to suctioning is incorrect as it can lead to hypoxemia in clients with
You may also like to solve these questions
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
- A. Serum creatinine
- B. Serum potassium
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (B) are more indicative of electrolyte balance, white blood cell count (C) indicates immune response, and hemoglobin level (D) reflects oxygen-carrying capacity.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
- A. Continue to monitor the client.
- B. Notify the healthcare provider immediately.
- C. Increase the suction level.
- D. Reposition the client.
Correct Answer: A
Rationale: The correct answer is A. The rise in the water seal chamber with client inspiration indicates that the chest tube system is functioning properly. This rise is expected as the negative pressure in the pleural space increases during inspiration, causing the water level to momentarily increase. It is important for the nurse to understand this physiological response and continue to monitor the client for any signs of respiratory distress. Notifying the healthcare provider immediately or increasing suction level is unnecessary and may disrupt the client's respiratory status. Repositioning the client is not indicated in this situation.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
- A. Do not apply heat to the area of irradiation.
- B. Use sunscreen on the irradiated area.
- C. Apply lotion generously to the irradiated area.
- D. Rub the area with an alcohol-based lotion.
Correct Answer: A
Rationale: Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.