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A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
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A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
- A. Drowsiness
- B. Gingival hyperplasia
- C. Skin rash
- D. Mild nausea
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (B) and mild nausea (D) are common side effects that do not require immediate reporting.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
- A. Bronchoconstriction
- B. Refractory hypoxemia
- C. Pulmonary hypertension
- D. Pleural effusion
Correct Answer: B
Rationale: Correct Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep the medication refrigerated.
- B. I will mix the medication with juice before taking it.
- C. I will stop taking the medication when I feel better.
- D. I will take the medication on an empty stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will keep the medication refrigerated." This is correct because cephalexin oral suspension should be stored in the refrigerator to maintain its potency and stability. Storing it at room temperature may lead to degradation of the medication. Choice B is incorrect as cephalexin should be taken as prescribed, not mixed with juice. Choice C is incorrect as the full course of antibiotics should be completed even if the client feels better. Choice D is incorrect as cephalexin can be taken with or without food.