Nokea
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
- A. Administer prescribed anxiolytic medication.
- B. Ensure informed consent is on the chart.
- C. Reinforce any teaching done previously.
- D. Start the preoperative antibiotic infusion.
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent is on the chart. This is the priority because obtaining informed consent is essential to ensure the client understands the procedure, risks, benefits, and alternatives. It protects the client's autonomy and ensures legal and ethical standards are met. Administering anxiolytic medication may help with anxiety but does not address the crucial issue of consent. Reinforcing teaching and starting antibiotics are important but secondary to obtaining informed consent.
You may also like to solve these questions
What should the nurse closely monitor for in a client who has undergone surgery for otosclerosis?
- A. Hypotension
- B. Nausea and vomiting
- C. Decreased urine output
- D. Abnormal facial nerve function
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications.
A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease.
B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action.
C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.
A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?
- A. Increased anterior-posterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, the lungs lose their elasticity, trapping air and causing hyperinflation. This leads to increased AP chest diameter due to barrel chest appearance. Option B is incorrect because COPD often results in an increased respiratory rate due to difficulty breathing. Option C is incorrect as weight gain is not a typical finding in COPD, which is often associated with weight loss. Option D is incorrect as a productive cough with yellow sputum is more commonly seen in respiratory infections rather than COPD exacerbations.
Which is a symptom of mental disorders?
- A. Anger
- B. Sleep deprivation
- C. Speech abnormalities
- D. Anxiety
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In which clients is electroconvulsive therapy (ECT) usually contraindicated?
- A. Clients with cardiac or neurovascular diseases
- B. Clients who have not responded to drug therapy
- C. Clients who are intolerant of the side effects of antidepressant medications
- D. Clients who are extremely suicidal
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.