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A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
- A. I will consult the provider to prescribe a sleep study to determine the problem.
- B. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
- C. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.
- D. Use pillows to elevate your head and chest while you are sleeping.
Correct Answer: D
Rationale: Elevating the head and chest can reduce fluid accumulation in the lungs, improving breathing and sleep quality in clients with advanced cardiac disease.
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A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority?
- A. Ineffective airway clearance related to edema
- B. Disturbed body image related to physical appearance
- C. Impaired urinary elimination related to fluid loss
- D. Risk for infection related to epidermal disruption
Correct Answer: A
Rationale: Airway clearance is the top priority in burn patients, especially with facial burns, as swelling can obstruct the airway.
Which high level labs should the nurse explain can prevent cardiovascular disease?
- A. Cholesterol
- B. Triglycerides
- C. Low-density lipoproteins (LDLs)
- D. High-density lipoproteins (HDLs)
Correct Answer: D
Rationale: HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs are not protective against cardiovascular disease.
Nurse Alice is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse should:
- A. Compress the sternum with both hands at a depth of 1½ to 2†(4 to 5 cm)
- B. Deliver 12 breaths/minute
- C. Perform only two-person CPR
- D. Use the heel of one hand for sternal compressions
Correct Answer: D
Rationale: For a 4-year-old, the heel of one hand is appropriate for sternal compressions to achieve the correct depth and avoid injury.
Severe hypothermia in newborn is defined as temperature below
- A. 28° C
- B. 30° C
- C. 32° C
- D. 34° C
Correct Answer: A
Rationale: Severe hypothermia in newborns is defined as a core body temperature below 28° C, which is life-threatening and requires immediate intervention.
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.