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A nurse is caring for a client receiving oxygen therapy via a nasal cannula. What is an important complication associated with prolonged use of a nasal cannula?
- A. Dry nasal passages
- B. Hypoventilation
- C. Hyperoxygenation
- D. Increased risk of infection
Correct Answer: A
Rationale: Prolonged use of a nasal cannula can lead to dryness and discomfort in the nasal passages due to the direct flow of oxygen. The nurse should provide humidification to prevent or alleviate dryness and nasal irritation.
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When planning care,for which client should the nurse include close observation for a decreased or absent cough reflex?
- A. The client with a nasal fracture
- B. The client with impairment of vagus nerve conduction
- C. The client with a sinus infection
- D. The client with reduction in respiratory membrane conduction
Correct Answer: B
Rationale: The cough reflex relies on vagus nerve (cranial nerve X) conduction to the medulla. Impairment of vagus nerve function (B) such as from spinal cord injury or CNS depression can decrease or eliminate the cough reflex increasing risks of aspiration and respiratory infections requiring close monitoring. Nasal fractures (A) and sinus infections (C) do not typically affect the cough reflex. Reduced respiratory membrane conduction (D) impacts gas exchange
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions
- B. We would give you oxygen through a tube in your nose
- C. You would give you oxygen through a tube in your nose.
- D. We would insert a breathing tube while we evaluate your condition
Correct Answer: B
Rationale: We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.
A nurse is assessing an older client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select ONE that does not apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
Correct Answer: A
Rationale: Pupil clarity, Visual fields, Visual acuity.
A patient with chronic obstructive pulmonary disease (COPD) is at risk for which complication?
- A. Hypoxemia
- B. Hyperoxia
- C. Bradycardia
- D. Hypertension
Correct Answer: A
Rationale: COPD impairs gas exchange, leading to hypoxemia (low blood oxygen) due to airway obstruction and alveolar damage, not hyperoxia, bradycardia, or hypertension.
Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?
- A. A 35-year-old patient using the incentive spirometer following abdominal surgery
- B. A 55-year-old patient who is eating in the chair following a rhinoplasty
- C. A 40-year-old patient who refuses to cough and deep breath following a splenectomy
- D. A 24-year-old patient ambulating in the hall following an appendectomy
Correct Answer: C
Rationale: This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.