Nokea
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
- A. Ensure the client has adequate sedation
- B. Find another provider to intubate
- C. Interrupt the procedure to give oxygen
- D. Monitor the client's oxygen saturation
Correct Answer: C
Rationale: Intubation attempts should not exceed 30 seconds to prevent hypoxia. Interrupting the procedure to provide oxygen is the priority to ensure the client's safety.
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The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
- A. Chest wall stiffness
- B. Decreased muscle strength
- C. Inability to cooperate
- D. Less lung elasticity
- E. Poor vision and hearing
Correct Answer: A,B,D
Rationale: Age-related changes like chest wall stiffness, decreased muscle strength, and reduced lung elasticity impair weaning from mechanical ventilation. Inability to cooperate and sensory deficits are not universal in older adults.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
- A. Alteplase (Activase)
- B. Enoxaparin (Lovenox)
- C. Unfractionated heparin
- D. Warfarin sodium (Coumadin)
Correct Answer: A
Rationale: Alteplase is a thrombolytic indicated for large pulmonary embolisms with hemodynamic instability to rapidly dissolve the clot and restore circulation.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
- A. Client who had a reaction to contrast dye yesterday
- B. Client with a new spinal cord injury on a rotating bed
- C. Middle-aged man with an exacerbation of asthma
- D. Older client who is 1-day post hip replacement surgery
- E. Young obese client with a fractured femur
Correct Answer: B,D,E
Rationale: Risk factors for PE include prolonged immobility (spinal cord injury, post-hip surgery), obesity, and trauma (fractured femur). Contrast dye reaction and asthma are not associated with increased PE risk.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
- A. Allow visitors at the client's bedside
- B. Ensure the client can communicate if awake
- C. Keep the television tuned to a favorite channel
- D. Provide back and hand massages when turning
- E. Turn the client every 2 hours or more
Correct Answer: A,B,D,E
Rationale: Comfort measures for ventilated clients include allowing visitors, enabling communication (e.g., via writing boards), providing massages during turning, and frequent repositioning to prevent pressure injuries. Keeping the TV on may disrupt rest.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess the client for sedation needs
- B. Get family permission for restraints
- C. Provide frequent oral care per protocol
- D. Use nonverbal pain assessment tools
Correct Answer: C
Rationale: Frequent oral care is within the UAP's scope of practice and is essential for ventilated clients to prevent ventilator-associated pneumonia. The other tasks require nursing judgment and cannot be delegated.