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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often, since it is not controlling my pain
- B. Breathing faster will help me keep my mind off of the pain
- C. It might help me to listen to music while I’m lying in bed
- D. I don’t want to walk today because I have some pain
Correct Answer: C
Rationale: It might help me to listen to music while I’m lying in bed.
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A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?
- A. Continue to assess.
- B. Notify the provider.
- C. Administer mannitol.
- D. Maintain supine position.
Correct Answer: A
Rationale: An ICP reading of $12 \mathrm{~mm} \mathrm{Hg}$ is within the normal range (10 to $15 \mathrm{~mm} \mathrm{Hg}$ ). The nurse would continue with ongoing neurological assessment including vital signs, pupillary function, cranial nerve function, Glasgow Coma Scale, and sensory and motor response.
The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation?
- A. The nurse's feelings about having used the SRD
- B. The specific type of SRD used and assessment of the patient.
- C. Confirmation of a prn order for use of the SRD
- D. Evidence that the patient was assessed every 8 hours
Correct Answer: B
Rationale: Documentation for SRDs must include objective patient-centered information. The nurse's feelings (A) are subjective and inappropriate for documentation. The specific type of SRD and patient assessment (B) are essential to ensure continuity of care and monitor for complications. Confirmation of a PRN order (C) is necessary to validate the use of SRDs. Assessing every 8 hours (D) is insufficient; SRDs require more frequent checks (e.g. every 1-2 hours) to ensure safety making B and C correct.
A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to
- A. improve oxygenation.
- B. remove irritants from the nasal passages.
- C. remove irritants from the trachea or bronchi.
- D. close the glottis.
Correct Answer: C
Rationale: Coughing removes irritants from the trachea and bronchi (C) where mucus traps particles and cilia sweep them upward. It does not primarily improve oxygenation (A) or involve nasal passages (B). Closing the glottis (D) is unrelated to cough function making C the correct purpose especially relevant after smoke inhalation.
The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?
- A. The ability to cough
- B. Filtration and humidification of inspired air
- C. The sneeze reflex initiated by irritants in the nasal passages
- D. Decrease in oxygen-carrying capacity of the trachea
Correct Answer: B
Rationale: A tracheostomy bypasses the nasal passages which normally filter humidify and warm inspired air (B). This protective mechanism is lost increasing the risk of respiratory infections and dryness requiring monitoring. The ability to cough (A) is not directly affected by the tracheostomy. The sneeze reflex (C) is irrelevant as it involves nasal passages. Decreased oxygen-carrying capacity (D) is not a protective mechanism and is unrelated to tracheostomy effects making B correct.
A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?
- A. Assessing the client's oxygen saturation every 4 hours
- B. Monitoring the client's respiratory rate every 15 minutes
- C. Providing frequent oral care to prevent dry mouth
- D. Administering oxygen at a flow rate of 1-2 L/min
Correct Answer: C
Rationale: NPPV devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP), can cause dry mouth. Providing frequent oral care, such as mouth rinses and moisturizing agents, helps alleviate discomfort and prevent oral complications.