Nokea
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?
- A. Respiratory rate of 8 to 10 per minute
- B. Pain level decreased from 6/10 to 2/10
- C. Client requests room door be closed
- D. Heart rate 90-100 per minute
Correct Answer: A
Rationale: Oxycodone can depress respiration; a respiratory rate of 8-10 per minute is abnormally low and requires immediate attention to prevent respiratory failure.
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A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?
- A. Bring a list of all medications and their purposes.
- B. Keep the doctor's phone number close by.
- C. Ensure all providers wash their hands before entering the room.
- D. Document the name of each caregiver who enters the room.
Correct Answer: A
Rationale: The correct answer is A: Bring a list of all medications and their purposes. This is important as it helps prevent medication errors during the surgical procedure. By having a list of medications and their purposes, the healthcare team can ensure they are administering the correct medications and dosages. This also helps in preventing drug interactions or allergies.
Option B (Keep the doctor's phone number close by) may be helpful in case of emergencies, but it does not directly address preventing errors during the surgical procedure. Option C (Ensure all providers wash their hands before entering the room) is important for infection control but is not specifically related to preventing errors. Option D (Document the name of each caregiver who enters the room) is not as critical as having a list of medications, as it does not directly impact the safety and well-being of the client during the surgical procedure.
For Mr. Jones’ persistent productive cough, what nursing action would be most appropriate?
- A. Increase intake of warm liquids
- B. Administer narcotic cough medication
- C. Monitor the amount of sputum produced each day
- D. Place the patient on strict bed rest
Correct Answer: A
Rationale: Warm liquids soothe the throat and thin mucus, facilitating expectoration.
What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?
- A. Administer humidified oxygen, as ordered
- B. Obtain an order for aspirin
- C. Auscultate the posterior basal segments for rales and rhonchi
- D. Explain the diagnosis to the patient
Correct Answer: A
Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Assess the client's vital signs including oxygen saturation.
- C. Notify the Rapid Response Team immediately.
- D. Place the client in a high Fowler's position.
Correct Answer: D
Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress.
Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.
Patients returning from the operating room (OR) should be monitored for atelectasis. Why is this important?
- A. Immobility, anesthesia, and lack of deep breathing place the patient at risk for collapsed lung.
- B. All postoperative patients are at risk for infection.
- C. Postoperative patients might have received too much oxygen during surgery.
- D. Postoperative patients do not receive enough oxygen during surgery.
Correct Answer: A
Rationale: Anesthesia and immobility can lead to atelectasis, where parts of the lung collapse.