Nokea
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse take?
- A. Check the ventilator settings every 8 hr.
- B. Suction the endotracheal tube every 4 hr.
- C. Monitor the client's oxygen saturation continuously.
- D. Administer a bronchodilator every 12 hr.
Correct Answer: C
Rationale: Continuous oxygen saturation monitoring ensures adequate ventilation. Settings checks, suctioning, and bronchodilators depend on specific needs, not fixed schedules.
You may also like to solve these questions
A nurse is caring for a client who is receiving continuous bladder irrigation following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports bladder spasms.
- B. The irrigation fluid is slightly pink.
- C. The client's urine output is bright red with clots.
- D. The client's catheter is draining freely.
Correct Answer: C
Rationale: Bright red urine with clots indicates potential hemorrhage, requiring immediate reporting. Spasms and pink fluid are expected, and free drainage is normal.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse report to the provider?
- A. The client's oxygen saturation is 95%.
- B. The client's cuff pressure is 35 cm H2O.
- C. The client's respiratory rate is 16 breaths/min.
- D. The client's temperature is 37.1°C (98.8°F).
Correct Answer: B
Rationale: A cuff pressure of 35 cm H2O (above 20-30 cm H2O) risks tracheal damage, requiring reporting. Normal saturation, respiratory rate, and temperature are unremarkable.
A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid deep breathing exercises.
- C. Apply a warm compress to the incision site.
- D. Administer a sedative every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like thromboembolism. Deep breathing aids recovery, warm compresses risk infection, and sedatives aren't routine.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent infection?
- A. Change the IV tubing every 24 hr.
- B. Clean the IV insertion site with alcohol before insertion.
- C. Monitor the IV site for redness or swelling.
- D. Use a new IV catheter for each attempt.
Correct Answer: C
Rationale: Monitoring for redness or swelling detects infection early. Tubing changes are every 72-96 hours, alcohol is standard, and new catheters are used per attempt.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?
- A. You should take this medication on an empty stomach.
- B. You might experience weight gain while taking this medication.
- C. You can stop taking this medication as soon as your symptoms improve.
- D. You need to avoid eating dairy products while taking this medication.
Correct Answer: B
Rationale: Prednisone can cause weight gain due to fluid retention and appetite increase. It's taken with food, tapered gradually, and dairy isn't restricted.