Nokea
A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse should plan to have which intervention supplies/equipment readily available at the client's bedside to ensure a safe environment?
- A. Code cart
- B. Intubation tray
- C. Thoracentesis tray
- D. Chest tube and drainage system
Correct Answer: B
Rationale: Respiratory failure occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client's compensatory mechanisms fail. The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside. A code cart is used for resuscitation. A thoracentesis tray contains the necessary items for performing a thoracentesis. A chest tube drainage system is used to treat a pneumothorax.
You may also like to solve these questions
The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?
- A. Elevate the foot of the bed.
- B. Put the bed in reverse Trendelenburg.
- C. Position the residual limb flat on the bed.
- D. Keep the residual limb slightly elevated with the client lying on the operative side.
Correct Answer: D
Rationale: Following an above-the-knee amputation, the residual limb is typically elevated for the first 24 hours to reduce swelling and promote venous return, which helps prevent complications such as edema. Positioning the client on the operative side with the residual limb slightly elevated (e.g., on a pillow) is the safest initial action to achieve this. Elevating the foot of the bed (option 1) may not specifically target the residual limb and could cause discomfort. Reverse Trendelenburg (option 2) elevates the head, which is not relevant to limb positioning. Keeping the limb flat (option 3) does not address swelling reduction.
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
- A. Applying both ice and a compression dressing to the knee while sitting.
- B. Obtaining a walker to minimize weight-bearing by the client on the affected leg.
- C. First applying a knee immobilizer and then elevating the affect leg while sitting.
- D. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
Correct Answer: C
Rationale: After a total knee replacement, as prescribed, the nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The leg is elevated while the client is sitting in the chair to minimize edema. A compression dressing should already be in place on the wound. Ice is not used unless prescribed. The surgeon prescribes the weight-bearing limits on the affected leg. A CPM machine is used only while the client is in bed and is initiated when prescribed.
A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?
- A. Inform the friend to directly contact the family and offer assistance to them.
- B. Request that the friend come to the client's home during the next home health visit.
- C. Report the friend's call to the nurse manager for referral to the client's social worker.
- D. Assure the friend that there is no need for assistance since the nurse is visiting daily.
Correct Answer: A
Rationale: The nurse must uphold the client's rights and does not give any information regarding a client's care needs to anyone who is not directly involved in the client's care. To request that the friend come for teaching is a direct violation of the client's right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend's assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.
The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position should the nurse assist the client into to maintain safety during the procedure?
- A. Right side-lying with the head of the bed flat
- B. Prone with the head turned toward the affected side
- C. Sims' position with the head of the bed elevated 45 degrees
- D. Left side-lying with the head of the bed elevated 45 degrees
Correct Answer: D
Rationale: A thoracentesis is a procedure in which fluid or air is removed from the pleural space via a transthoracic aspiration. Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.
A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)?
- A. An apnea monitor
- B. A suction unit and oxygen
- C. A blood transfusion warmer
- D. An ampule of phytonadione
Correct Answer: B
Rationale: After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Phytonadione would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration.