Nokea
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
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The client has had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client in stump care. Which of the following statements by the client indicates that she understands how to implement her plan of care?
- A. I should inspect the incision carefully when I change the dressing every other day.'
- B. I should wash the incision, dry it, and apply moisturizing lotion daily.'
- C. I should rewrap the stump as often as needed.'
- D. I should elevate the stump on pillows to decrease swelling.'
Correct Answer: C
Rationale: Rewrapping the stump as often as needed ensures proper compression to shape the stump for a prosthesis and reduce edema, indicating correct understanding of stump care. Inspecting every other day may be insufficient, washing and moisturizing the incision risks infection, and elevating on pillows is not standard for arterial disease.
A middle-aged man collapses in the emergency department waiting room. The triage nurse should first:
- A. Gently shake the victim and ask him to state his name.
- B. Perform the chin-tilt to open the victim's airway.
- C. Feel for any air movement from the victim's nose or mouth.
- D. Watch the victim's chest for respirations.
Correct Answer: A
Rationale: The first step in assessing an unresponsive patient is to check for responsiveness by gently shaking and calling out to the victim, per AHA guidelines, to determine if CPR or other interventions are needed.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler’s.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.