Nokea
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
- A. Administer prescribed anxiolytic medication.
- B. Ensure informed consent is on the chart.
- C. Reinforce any teaching done previously.
- D. Start the preoperative antibiotic infusion.
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent is on the chart. This is the priority because obtaining informed consent is essential to ensure the client understands the procedure, risks, benefits, and alternatives. It protects the client's autonomy and ensures legal and ethical standards are met. Administering anxiolytic medication may help with anxiety but does not address the crucial issue of consent. Reinforcing teaching and starting antibiotics are important but secondary to obtaining informed consent.
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The physician has ordered continuous positive airway pressure (CPAP) for a patient with serious obstructive sleep apnea. How will CPAP help the patient?
- A. Prevent airway occlusion by bringing the tongue forward
- B. Be easily tolerated by both the patient and the patient’s bed partner
- C. Provide enough positive pressure in the airway to prevent airway collapse
- D. Deliver a high inspiratory pressure and a low expiratory pressure to prevent airway collapse
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Mr. Jones wants to lose 2 lb/wk. How many calories must he reduce daily?
- A. 300
- B. 500
- C. 1000
- D. 1200
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is prescribed albuterol (Proventil) via a metered-dose inhaler. Which action should the nurse take to ensure effective use of this medication?
- A. Instruct the client to inhale quickly while administering the medication.
- B. Have the client hold their breath for 10 seconds after inhaling the medication.
- C. Tell the client to exhale immediately after inhaling the medication.
- D. Encourage the client to use the inhaler as needed only when experiencing symptoms.
Correct Answer: B
Rationale: The correct answer is B: Have the client hold their breath for 10 seconds after inhaling the medication. This action promotes medication deposition in the lungs by allowing the albuterol to reach deeper into the airways. Holding the breath for 10 seconds ensures better absorption and effectiveness of the medication.
Explanation of Incorrect Choices:
A: Inhaling quickly may cause the medication to not reach the lower airways effectively.
C: Exhaling immediately after inhaling the medication can decrease the amount of medication reaching the lungs.
D: Using the inhaler only when experiencing symptoms may lead to ineffective management of respiratory conditions.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
- A. I will take my medication as prescribed.
- B. I will need to have regular follow-up chest x-rays.
- C. I will be able to return to work immediately.
- D. I will use tissues to cover my mouth when I cough.
Correct Answer: C
Rationale: The correct answer is C because a client with TB should not return to work immediately due to the risk of spreading the infection. Taking medication as prescribed (A), having regular follow-up chest x-rays (B), and using tissues to cover the mouth when coughing (D) are all important aspects of managing TB and preventing its spread. Returning to work immediately can put coworkers at risk of contracting TB. Therefore, the client should understand the importance of taking precautions and following healthcare provider recommendations to ensure proper treatment and prevent transmission of the disease.