Nokea
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.
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While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)
- A. What response do you have when you eat avocados?
- B. I will remove any avocados that are on your food tray
- C. Ask about the last time you ate avocados
- D. I will document this in your record so all of your providers will know
- E. Have you ever been treated for this allergic reaction?
Correct Answer: A,D,E
Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.
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.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?
- A. Assistance with activities of daily living
- B. Assess the client's oxygen saturation levels
- C. Oxygen therapy at 2 liters per nasal cannula
- D. Complete bedrest with frequent repositioning
Correct Answer: A
Rationale: Dyspnea with activity intolerance, such as stopping multiple times while climbing stairs, indicates functional limitation (class III). Assistance with activities of daily living supports the client's needs without restricting activity unnecessarily. Oxygen therapy or bedrest may not be indicated unless hypoxia or severe limitation is present.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. Oxygen saturation is 92% after a 12-minute walk
- B. A small amount of drainage from the site is noted
- C. Pulse oximetry is 95% on 2 liters of oxygen
- D. The trachea is deviated toward the opposite side of the neck
Correct Answer: D
Rationale: A deviated trachea indicates a tension pneumothorax, a medical emergency requiring immediate intervention. Other findings, such as small drainage or 95% pulse oximetry, are normal or near-normal and do not require urgent action.
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercises?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: An equal AP and lateral chest diameter suggests a barrel chest, often associated with chronic airflow limitation conditions like COPD or severe asthma. Asking about chronic breathing problems directly addresses the potential underlying cause. Other options are less relevant to this specific finding.