Nokea
A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?
- A. Offer to contact the family's spiritual counselor to meet with the client and spouse.
- B. Discuss comfort measures with the client and family that will be available during withdrawal.
- C. Inform the healthcare provider of the client's desire to have life support withdrawn.
- D. Explain the actions that the healthcare team will follow for the removal of life support.
Correct Answer: C
Rationale: Notifying provider respects client autonomy.
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After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Secure an allergy bracelet around the client's wrist.
- B. Notify the dietary department of the client's fruit allergy.
- C. Send a list of medication allergies to the pharmacy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: A
Rationale: Allergy bracelet prevents immediate exposure.
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
- A. Record the client's pulse rate and rhythm.
- B. Assist the client to stand at the bedside.
- C. Apply the blood pressure cuff securely.
- D. Position the client supine for a few minutes.
Correct Answer: D
Rationale: Supine position provides baseline for orthostatic assessment.
When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Securely place the prongs of the cannula in the nostrils.
- C. Place the pulse oximeter on the client's earlobe.
- D. Document the second reading in the client's record.
Correct Answer: B
Rationale: Proper cannula placement ensures oxygen delivery.