Nokea
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea,tachycardia and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement ALL priority interventions EXCEPT?
- A. Administer oxygen
- B. Administer furosemide (diuretic)
- C. Transport to coronary care unit
- D. Obtain stat Hepatic Panel
Correct Answer: C
Rationale: Rationale: Option C, transporting the client to the coronary care unit, is not the priority intervention because the client is presenting with acute pulmonary edema, a sign of worsening heart failure. Administering oxygen (Option A) is crucial to improve oxygenation. Administering furosemide (Option B) helps reduce fluid overload. Obtaining a stat Hepatic Panel (Option D) may be necessary to assess liver function due to medication side effects. However, immediate actions to address respiratory distress and tachycardia take precedence over moving the client to another unit.
You may also like to solve these questions
The term "blue bloater" refers to which of the following conditions?
- A. Acute respiratory distress syndrome (ARDS)
- B. Asthma
- C. Chronic obstructive bronchitis
- D. Emphysema
Correct Answer: C
Rationale: The correct answer is C: Chronic obstructive bronchitis. The term "blue bloater" is a classic descriptor used in the context of chronic obstructive bronchitis. It refers to patients who exhibit cyanosis (blue discoloration of the skin due to lack of oxygen) and are often overweight and edematous. This term is used to differentiate from "pink puffers" who have emphysema. Both conditions are part of chronic obstructive pulmonary disease (COPD), but the "blue bloater" presentation is more characteristic of chronic bronchitis due to the chronic hypoxia and retained carbon dioxide.
Now, let's evaluate why the other choices are incorrect:
A: Acute respiratory distress syndrome (ARDS) typically presents with severe difficulty breathing and rapid onset of respiratory failure. It is not referred to as a "blue bloater."
B: Asthma is characterized by reversible airway obstruction and wheezing, usually triggered by allergens or irrit
The nurse recognizes that additional teaching is needed when the patient with asthma says
- A. a. I should exercise every day if my symptoms are controlled.
- B. b. I may use over-the-counter bronchodilator drugs occasionally if I develop chest tightness.
- C. c. I should inform my spouse about my medications and how to get help if I have a severe asthma attack.
- D. A diary to record my medication use, symptoms, peak expiratory flow rates, and activity levels will help in adjusting my therapy.
Correct Answer: D
Rationale: Additional teaching is needed when the patient mentions using over-the-counter bronchodilator drugs occasionally. This is not recommended as it can mask underlying issues and delay proper treatment.
Carbon monoxide
- A. has a very low affinity or attraction to hemoglobin.
- B. is unlikely to be transported by the circulatory system.
- C. is not the cause of death of people who breathe excessive amounts of automobile exhausts.
- D. can arise from cigarette smoke
Correct Answer: D
Rationale: The correct answer is D because carbon monoxide can indeed arise from cigarette smoke due to incomplete combustion of tobacco. This is supported by scientific evidence. Carbon monoxide has a high affinity for hemoglobin, so choice A is incorrect. It can be transported by the circulatory system, making choice B incorrect. Breathing excessive amounts of automobile exhaust containing carbon monoxide can lead to death, making choice C incorrect.
Pneumatic and inhibitory centers are associated with
- A. Respiration
- B. Breathing
- C. Inspiration
- D. Expiration
Correct Answer: B
Rationale: The correct answer is B: Breathing. Pneumatic and inhibitory centers are associated with controlling the process of breathing. The pneumatic center regulates the rate and depth of breathing, while the inhibitory center helps in controlling the duration and intensity of breathing. Therefore, these centers are directly involved in the overall process of breathing. Choices A, C, and D are incorrect as they are specific components or stages of the breathing process, whereas the correct answer encompasses the entire act of breathing, making it the most comprehensive and appropriate choice.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 L of oxygen.
- D. The trachea is shifted toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because the trachea shifted towards the opposite side indicates a potential pneumothorax, a serious complication following thoracentesis. Immediate action is needed to prevent respiratory distress. Choices A and B are common post-procedural findings and may not require immediate action. Choice C, while indicating hypoxemia, does not pose an immediate threat compared to a tracheal deviation.