Nokea
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?
- A. Measure oxygen saturation before and after a 12-minute walk.
- B. Verify that the client understands all possible complications.
- C. Explain the procedure in detail to the client and the family.
- D. Validate that informed consent has been given by the client.
Correct Answer: D
Rationale: The correct answer is D. Validating that informed consent has been given by the client is crucial before any invasive procedure to ensure the client understands the risks, benefits, and alternatives. It also respects the client's autonomy and right to make an informed decision.
A: Measuring oxygen saturation before and after a 12-minute walk is not directly related to thoracentesis preparation.
B: Verifying the client's understanding of complications is important but not the immediate priority before the procedure.
C: Explaining the procedure to the client and family is essential but may not be the first step; ensuring informed consent comes before this step.
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The lower respiratory tract is consist except
- A. Nose
- B. bronchioleg
- C. Trachea
- D. both b and c
Correct Answer: A
Rationale: The correct answer is A: Nose. The lower respiratory tract includes the trachea, bronchioles, and lungs, but not the nose. The nose is a part of the upper respiratory tract, responsible for filtering, humidifying, and warming inhaled air. The trachea and bronchioles are part of the lower respiratory tract, involved in the passage of air into the lungs for gas exchange. Therefore, the nose does not belong to the lower respiratory tract, making it the correct answer. Choices B and C (bronchioles and trachea) are incorrect as they are part of the lower respiratory tract. Choice D is incorrect because both the bronchioles and trachea are part of the lower respiratory tract.
A client is found to be allergic to Chinese food, which causes acute asthma. Which of the following instructions should the nurse give the client?
- A. "Only eat Chinese food once a month."
- B. "Use your inhalers before eating Chinese food."
- C. "Avoid Chinese food because this is a trigger for you."
- D. "Determine other causes, because Chinese food wouldn't cause such a violent reaction."
Correct Answer: C
Rationale: Rationale: Choice C is correct because avoiding Chinese food, a known trigger for the client's acute asthma, is crucial to prevent future asthma attacks. By eliminating the trigger, the client can reduce the risk of allergic reactions and asthma exacerbations.
Summary:
A: Incorrect. Eating Chinese food once a month still exposes the client to the trigger, increasing the risk of asthma attacks.
B: Incorrect. Using inhalers before eating Chinese food may help manage symptoms temporarily but does not address the root cause of the allergic reaction.
D: Incorrect. Dismissing the client's known trigger without further investigation can lead to serious health consequences.
The emergency department (ED) manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?
- A. Antibiotics started before admission.
- B. Blood cultures obtained within 20 minutes.
- C. Chest x-ray obtained within 30 minutes.
- D. Pulse oximetry obtained on all clients.
Correct Answer: A
Rationale: The correct answer is A: Antibiotics started before admission. This outcome demonstrates that the staff are meeting the goal for treating clients with community-acquired pneumonia because timely administration of antibiotics is crucial in managing this condition effectively. Starting antibiotics promptly helps to reduce the spread of infection and improve patient outcomes.
Blood cultures obtained within 20 minutes (B) is important for diagnosing the specific pathogen causing pneumonia but does not directly reflect the treatment goal achievement. Chest x-ray within 30 minutes (C) is essential for diagnosis but does not indicate treatment success. Pulse oximetry on all clients (D) is important for monitoring oxygen levels but does not directly show if the treatment goal for pneumonia has been met.
BCG vaccine is used to curb
- A. Pneumonia
- B. Tuberculosis
- C. Emphysema
- D. Small pox
Correct Answer: B
Rationale: The correct answer is B: Tuberculosis. BCG vaccine is specifically designed to prevent tuberculosis, which is a bacterial infection caused by Mycobacterium tuberculosis. The vaccine stimulates the immune system to provide protection against TB. Pneumonia (A), Emphysema (C), and Smallpox (D) are not targeted by the BCG vaccine. Pneumonia is usually caused by viruses or bacteria different from TB, Emphysema is a chronic lung condition unrelated to TB, and Smallpox is caused by the Variola virus, which is different from the bacteria causing TB. Therefore, the correct answer is B as BCG vaccine is used to curb tuberculosis.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
- A. Encourage oral feeding as soon as possible.
- B. Develop an alternative communication method.
- C. Keep the tracheostomy cuff fully inflated.
- D. Keep the patient flat in bed.
Correct Answer: B
Rationale: The correct answer is B: Develop an alternative communication method. After a total laryngectomy, the patient loses the ability to speak. Developing an alternative communication method such as using a communication board or electronic device is crucial for effective communication. Encouraging oral feeding (A) is not appropriate initially due to the risk of aspiration. Keeping the tracheostomy cuff fully inflated (C) can obstruct airflow, and keeping the patient flat in bed (D) can lead to respiratory complications. Developing an alternative communication method is essential for the patient's emotional well-being and quality of life.