Nokea
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowler position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.
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The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
- A. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
- B. 52-yr-old with a blood pressure of 198/90 mm Hg who has leg cramping
- C. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.1 mg/dL
- D. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain first because chest pain can be a sign of a cardiac issue, which could be life-threatening. Assessing this patient first is crucial to rule out any acute cardiac events. Leg cramping (choice B) is a common symptom in hypertensive patients but is not as urgent as chest pain. High creatinine levels (choice C) may indicate kidney issues but do not require immediate assessment compared to chest pain. Microalbuminuria (choice D) is a sign of kidney damage in hypertension but does not pose an immediate threat like chest pain.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
- A. Inform the physician.
- B. Continue to monitor the client.
- C. Reinforce the occlusive dressing.
- D. Encourage the client to deep breathe.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. Fluctuation of fluid level in the water seal chamber post chest tube insertion indicates proper functioning of the chest tube system. This signifies that the tube is effectively draining fluid or air from the pleural space. It is essential to continue monitoring the client to ensure ongoing proper functioning of the chest tube. Informing the physician (Choice A) is not necessary at this point unless there are other concerning symptoms. Reinforcing the occlusive dressing (Choice C) is not indicated unless there is a leak or issue with the dressing. Encouraging the client to deep breathe (Choice D) is unrelated to the assessment of the chest tube system.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
- A. 15 to 60 seconds.
- B. 5 to 20 minutes.
- C. 30 to 40 minutes.
- D. 45 to 60 minutes.
Correct Answer: B
Rationale: The correct answer is B: 5 to 20 minutes. Plugging the tracheostomy tube for this duration allows the client to gradually adapt to breathing without the assistance of the tube. Initially, the client may experience increased respiratory effort, which helps improve lung function. Plugging the tube for too short a time (A) may not provide enough challenge for the client, while plugging it for too long (C, D) may cause distress or potential complications due to lack of oxygen. Therefore, the optimal time frame of 5 to 20 minutes ensures a safe and effective weaning process for the client.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.