Nokea
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an advanced treatment
- B. Notify the Rapid Response Team
- C. Assess the clients peripheral pulses
- D. Obtain blood and sputum cultures
Correct Answer: B
Rationale: Continuous cyanosis despite oxygen therapy suggests methemoglobinemia, a serious adverse effect of benzocaine spray. Notifying the Rapid Response Team is critical for immediate advanced care. Other actions do not address the urgent oxygenation issue.
You may also like to solve these questions
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
- A. Measure oxygen saturation 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 to the client
Correct Answer: D
Rationale: Validating informed consent is critical before an invasive procedure like thoracentesis to ensure the client is aware of risks and agrees to the procedure. Explaining the procedure and verifying complications are typically the physician's responsibility, and a 12-minute walk is not relevant.
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has to exposed your smoking history. Which action is most important for the nurse to take when interviewing this client?
- A. Tell a client that he needs to quit smoking to stop further cancer development
- B. Encourage the client to be completely honest about both tobacco and marijuana use
- C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty
- D. Avoid giving the client false hope regarding cancer treatment and prognosis
Correct Answer: C
Rationale: Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have quit or be in denial about this habit, a nonjudgmental attitude during the interview encourages honesty about exposure. Asking about current or past use and passive exposure is important, but maintaining a nonjudgmental attitude is the priority to facilitate open communication.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
- A. Encourage the client to increase fluid intake
- B. Assess the clients level of consciousness
- C. Raise the head of the bed to at least 45 degrees
- D. Provide the client with humidified oxygen
Correct Answer: B
Rationale: Assessing the client's level of consciousness is critical as it indicates how the client is responding to the infection and its impact on overall health. While encouraging fluid intake, raising the head of the bed, and providing humidified oxygen are important interventions, they are secondary to assessing consciousness, which can reveal urgent changes in the client's condition.
A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?
- A. Make a list of reasons why smoking is a bad habit
- B. Rise slowly when getting out of bed in the morning
- C. Smoking while taking this medication will increase your risk of a stroke
- D. Stopping this medication suddenly increases your risk for a heart attack
Correct Answer: C
Rationale: Smoking while using nicotine replacement therapy increases cardiovascular risks, including stroke. The nurse should emphasize avoiding smoking during treatment. Other statements are not directly relevant to nicotine replacement therapy.
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which findings should the nurse identify as adverse effects of this medication? (Select all that apply.)
- A. Visual hallucinations
- B. Tachycardia
- C. Decreased cravings
- D. Impaired judgment
- E. Increased thirst
Correct Answer: A,D
Rationale: Varenicline has a black box warning for causing behavioral changes, including visual hallucinations and impaired judgment. Tachycardia and increased thirst are not associated adverse effects, while decreased cravings is a desired therapeutic effect.