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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
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A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
- A. I should position the baby the same way for each feeding.'
- B. I should make sure the baby grasps the entire areola and nipple.'
- C. I should air dry my breasts and nipples for 10 to 15 minutes after the feeding.'
- D. I shouldn't use a hand breast pump if my nipples get sore.'
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
- A. Use distracting techniques when appropriate.
- B. Be consistently visible and available to the clients.
- C. Provide reality orientation to the clients as needed.
- D. Anticipate the needs of the clients as much as possible.
- E. Segregate potentially volatile clients from the other clients.
Correct Answer: A,B,C,D
Rationale: To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
- A. Tracheal deviation
- B. Mild dyspnea
- C. Oxygen saturation of 92%
- D. Subcutaneous emphysema
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
- A. Admission to the hospital.
- B. Transfer to the nursing home.
- C. Transfer of a client from surgery to the surgical unit.
- D. Admission to a home health agency from the hospital.
- E. Move from a double room to a single room on the same unit.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.