Nokea
A home health nurse is visiting a new client who uses oxygen in the home. For which factors doesn't the nurse assess when determining if the client is using the oxygen safely?
- A. The client does not allow smoking in the house.
- B. Electrical cords are in good working order.
- C. Flammable liquids are stored in the garage.
- D. Household light bulbs are the fluorescent type.
Correct Answer: D
Rationale: The correct answer is D because household light bulbs being fluorescent type is unrelated to the safe use of oxygen. The nurse should assess factors directly related to oxygen safety, such as smoking restrictions, electrical cord condition, and proper storage of flammable materials. Fluorescent light bulbs do not pose a significant risk in relation to oxygen safety.
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Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To help the client drink fluids
- C. To prevent respiratory obstruction
- D. To prevent excessive bleeding
Correct Answer: A
Rationale: The correct answer is A. An ice collar reduces swelling and pain by constricting blood vessels and numbing the area. B (helping the client drink fluids) is unrelated. C (preventing respiratory obstruction) is not the primary purpose of an ice collar. D (preventing excessive bleeding) is managed differently, usually with direct pressure or medication.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an albuterol treatment.
- B. Notify the Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Continuous cyanosis despite oxygen therapy following benzocaine administration may indicate methemoglobinemia, a serious adverse effect. Rapid Response Team should be alerted for immediate intervention and monitoring. Albuterol treatment (A) would not address methemoglobinemia. Assessing peripheral pulses (C) may not provide immediate assistance. Obtaining blood and sputum cultures (D) is not the priority in this situation.
Hypoxia
- A. causes hyperventilation
- B. may cause headaches, nausea, and lethargy.
- C. can lead to loss of consciousness and death
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D because hypoxia, which is a condition of low oxygen levels in the body, can indeed lead to hyperventilation, as the body tries to compensate. It can also cause symptoms like headaches, nausea, and lethargy due to the lack of oxygen reaching the brain and other organs. Severe hypoxia can lead to loss of consciousness and even death if oxygen levels are not restored promptly. Therefore, all the statements in choices A, B, and C are true in relation to hypoxia, making option D the correct choice.
Which of the following gas mixture is used by Divers to prevent Oxygen toxicity
- A. Oxygen and CO2
- B. Oxygen and Nitrogen
- C. Oxygen and rare gases
- D. Oxygen, CO2 and Nitrogen
Correct Answer: B
Rationale: The correct answer is B: Oxygen and Nitrogen. This gas mixture is used by divers to prevent Oxygen toxicity because it closely mimics the composition of the air we breathe. Oxygen toxicity can occur at high partial pressures of Oxygen, which can lead to seizures and other serious health issues. Choices A, C, and D are incorrect because CO2 and rare gases are not typically used in diving gas mixtures, and including CO2 in the mixture can increase the risk of Oxygen toxicity. Nitrogen is used as a diluent to reduce the partial pressure of Oxygen, making it safer for divers.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?
- A. Continue to suction.
- B. Notify the physician immediately.
- C. Stop the procedure and reoxygenate the client.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: C
Rationale: The correct answer is C: Stop the procedure and reoxygenate the client. When the nurse notes a decreasing heart rate during suctioning, it could indicate that the client is experiencing hypoxia. Stopping the procedure and providing additional oxygenation is crucial to prevent further complications such as bradycardia or cardiac arrest. Continuing to suction (choice A) can worsen the hypoxia. Notifying the physician immediately (choice B) may cause a delay in addressing the immediate issue. Limiting suction to 15 seconds (choice D) does not address the primary concern of hypoxia and decreasing heart rate.