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A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
- A. The client is able to ambulate in the hall without dyspnea.
- B. The client has a respiratory rate of 24 breaths per minute.
- C. The client's oxygen saturation is 92%.
- D. The client has a productive cough.
Correct Answer: A
Rationale: The correct answer is A because the ability to ambulate without dyspnea indicates effective oxygen therapy. When a client can move without experiencing difficulty breathing, it suggests that the oxygen therapy is adequately supporting their oxygenation needs. In contrast, options B, C, and D do not directly indicate the effectiveness of oxygen therapy. Option B (respiratory rate of 24 breaths per minute) may be within normal range but does not confirm the therapy's efficacy. Option C (oxygen saturation of 92%) is below the desired range of 95-100%, indicating inadequate oxygenation. Option D (productive cough) is unrelated to the assessment of oxygen therapy effectiveness.
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What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?
- A. Shake the inhaler well before use.
- B. Inhale rapidly while administering the medication.
- C. Administer the medication while lying down.
- D. Hold the inhaler 2 inches away from the mouth while inhaling.
Correct Answer: A
Rationale: Rationale for Correct Answer A:
1. Shaking the inhaler well before use helps ensure proper mixing of the medication.
2. This action helps to distribute the medication evenly for effective delivery.
3. It prevents clogging and ensures the client receives the correct dose.
4. Shake-and-use approach is essential for optimal therapeutic benefits.
Summary of Incorrect Choices:
B: Inhaling rapidly may lead to improper medication delivery and increase the risk of side effects.
C: Administering medication while lying down may not allow the client to inhale the medication effectively.
D: Holding the inhaler too far away can result in decreased medication intake and reduced efficacy.
A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct Answer: B
Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent further complications. The other choices are incorrect because:
A: Production of pink sputum may indicate blood-tinged sputum, which could be a sign of minor bleeding but does not require immediate intervention.
C: Pain at insertion site is common after chest tube insertion and can be managed with pain medication, not necessarily requiring immediate intervention.
D: Sudden onset of shortness of breath could indicate various issues, including pneumothorax, but tracheal deviation is a more specific and urgent sign that requires immediate attention.
A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
- A. A 4-ounce steak, French fries, iceberg lettuce
- B. Baked chicken breast, broccoli, tomatoes
- C. Fried catfish, cornbread, peas
- D. Spaghetti with meat sauce, garlic bread
Correct Answer: B
Rationale: The correct answer is B because it includes a lean protein (baked chicken breast) and high-fiber vegetables (broccoli, tomatoes) which are beneficial for managing elevated lipid levels. Lean protein helps reduce saturated fat intake while fiber from vegetables aids in lowering cholesterol levels. Choice A includes a high-saturated fat steak and French fries, not ideal for managing lipid levels. Choice C contains fried catfish and cornbread which are high in unhealthy fats and refined carbohydrates. Choice D has spaghetti with meat sauce and garlic bread, which are high in refined carbohydrates and saturated fats, not recommended for someone with elevated lipid levels.
What information should you immediately report to the physician?
- A. The parent is unsure about the child's tetanus immunization status
- B. The child is upset and pulls out the IV
- C. The parent declines the IV conscious sedation
- D. The parent wants information about the IV conscious sedation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?
- A. Assistance with activities of daily living.
- B. Daily physical therapy activities.
- C. Oxygen therapy at 2 liters per nasal cannula.
- D. Complete bedrest with frequent repositioning.
Correct Answer: A
Rationale: The correct answer is A: Assistance with activities of daily living. Class III dyspnea signifies moderate exertion causing symptoms. Therefore, the client may need help with daily activities to conserve energy. Daily physical therapy (B) may be too strenuous. Oxygen therapy (C) may not be necessary at this point. Complete bedrest (D) can lead to deconditioning.