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A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation
- B. obtain a throat culture
- C. suction the child's oropharynx
- D. prepare a cool mist tent
Correct Answer: A
Rationale: The correct action is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the airway can become severely compromised due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. Prompt intervention is crucial to prevent respiratory distress and potential death. Obtaining a throat culture (B) may delay essential treatment. Suctioning the oropharynx (C) can stimulate the epiglottis and worsen the obstruction. A cool mist tent (D) does not address the immediate need for securing the airway.
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A nurse is caring for a client who has heart failure.
Which of the following manifestations should the nurse expect?
- A. Crackles in the lungs
- B. Bradycardia
- C. Dry mucous membranes
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Crackles in the lungs. This manifestation is expected in conditions like heart failure or pneumonia due to fluid accumulation in the lungs. Crackles are abnormal lung sounds heard on auscultation. Bradycardia (B) is a slow heart rate, not typically associated with these conditions. Dry mucous membranes (C) can indicate dehydration but are not specific to lung issues. Weight loss (D) may occur in chronic conditions but is not a direct manifestation of fluid in the lungs. Therefore, crackles in the lungs are the most likely manifestation to expect in this scenario.
A nurse is caring for a client in the emergency department. Nurses' Notes
1100:
The client reports shortness of breath and difficulty sleeping. The client feels tired very quickly
and occasionally feels nauseous. The client reports experiencing intermittent chest tightness and
a cough that is aggravated by exercise. The client has a productive cough and irregular breathing
pattern. Crackles and wheezing present on auscultation. The client has a history of smoking a
pack of cigarettes per day for the past 35 years. There is no clubbing of the fingers. The client
appears anxious.
1130:
Administered albuterol and oxygen per provider's prescription. The client is instructed to perform
pursed-lip breathing.
1230:
The client is breathing with minimal effort and coughing has decreased
Vital Signs 1100:
Temperature 36.8°C (98.2° F) Heart
rate 92/min Respiratory rate 28/min
BP 145/90 mm Hg
Oxygen saturation 87% on room air
1145:
Temperature 36.2° C (97.2" F) Heart
rate 88/min
Respiratory rate 22/min BP
140/90 mm Hg
Oxygen saturation 92% on room air
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.
A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. The client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.
A nurse is admitting an older adult client who was transferred from another facility.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube.
Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.