Nokea
A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to:
- A. Applying oxygen at 4 L via nasal cannula
- B. Removing the tube after deflating the balloons
- C. Elevating the head of the bed to 45°
- D. Increasing the pressure in the esophageal balloon
Correct Answer: B
Rationale: Respiratory distress with stridor suggests airway obstruction from the tamponade, requiring immediate tube removal after deflation to restore airway patency.
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The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
- A. Setting realistic limits
- B. Encouraging the client to express remorse for behavior
- C. Minimizing interactions with other clients
- D. Encouraging the client to act out feelings of rage
Correct Answer: A
Rationale: Setting realistic limits helps manage the manipulative and impulsive behaviors common in antisocial personality disorder, promoting safety and structure.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:
- A. 50-60 mm Hg
- B. 70-80 mm Hg
- C. 80-90 mm Hg
- D. 90-98 mm Hg
Correct Answer: B
Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
An 82-year-old woman is being admitted to a long-term care facility. Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale. To determine a Braden Scale score, the nurse evaluates all of the following EXCEPT
- A. nutritional status.
- B. sensory perception.
- C. past history of skin breakdown.
- D. activity level.
Correct Answer: C
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Past history of skin breakdown is not a scored category.