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A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
- A. Administer albuterol treatment.
- B. Notify Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.
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The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to:
- A. Check for subcutaneous emphysema in the upper torso.
- B. Reposition the client to a position of comfort.
- C. Call the health care provider as soon as possible.
- D. Check for any increase in the amount of thoracic drainage.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When teaching a patient to care for himself before discharge, what should the nurse initially do?
- A. Develop a 1-hour teaching session
- B. Give the patient a booklet to read
- C. Prioritize teaching needs
- D. Select specific teaching techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents?
- A. Knowledge of the agency's emergency response plan
- B. Awareness of the signs and symptoms for potential agents of bioterrorism
- C. Knowledge of how and what to report to the CDC
- D. Ethical decision-making about exposing self to potentially lethal substances
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In view of the fact that most older adults take at least six prescription drugs, what are four nursing interventions that can specifically help prevent problems caused by multiple drug use in older patients?
- A. Medication reconciliation
- B. Patient education regarding side effects
- C. Regular review of medication regimens
- D. Monitoring for drug interactions
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?
- A. Increased anterior-posterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, air trapping causes hyperinflation of the lungs, leading to an increase in the AP chest diameter known as barrel chest. This is a classic physical finding in patients with COPD due to chronic airway obstruction.
Explanation of other choices:
B: Decreased respiratory rate - In COPD, patients typically have an increased respiratory rate due to difficulty breathing.
C: Weight gain - Weight gain is not a typical finding in COPD and is more often associated with other medical conditions or lifestyle factors.
D: Productive cough with yellow sputum - While a productive cough is common in COPD, yellow sputum is more indicative of a bacterial infection rather than COPD alone.