Nokea
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation.
A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy.
C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy.
D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
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The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
- A. Administer prescribed anxiolytic medication.
- B. Ensure informed consent is on the chart.
- C. Reinforce any teaching done previously.
- D. Start the preoperative antibiotic infusion.
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent is on the chart. This is the priority because obtaining informed consent is essential to ensure the client understands the procedure, risks, benefits, and alternatives. It protects the client's autonomy and ensures legal and ethical standards are met. Administering anxiolytic medication may help with anxiety but does not address the crucial issue of consent. Reinforcing teaching and starting antibiotics are important but secondary to obtaining informed consent.
A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?
- A. Increased anterior-posterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, air trapping causes hyperinflation of the lungs, leading to an increase in the AP chest diameter known as barrel chest. This is a classic physical finding in patients with COPD due to chronic airway obstruction.
Explanation of other choices:
B: Decreased respiratory rate - In COPD, patients typically have an increased respiratory rate due to difficulty breathing.
C: Weight gain - Weight gain is not a typical finding in COPD and is more often associated with other medical conditions or lifestyle factors.
D: Productive cough with yellow sputum - While a productive cough is common in COPD, yellow sputum is more indicative of a bacterial infection rather than COPD alone.
What is the first action that you should direct the caller to perform?
- A. Call 911
- B. Remove the stinger by scraping
- C. Apply a cool compress
- D. Take an oral antihistamine
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client interested in smoking cessation is being taught by a nurse. Which statements should the nurse include in the teaching? (Select one that does not apply)
- A. Find an activity that you enjoy and will keep your hands busy.
- B. Keep snacks like potato chips on hand to nibble on.
- C. Drink at least eight glasses of water each day.
- D. Make a list of reasons for quitting smoking.
Correct Answer: C
Rationale: The correct answer is C: Drink at least eight glasses of water each day. This statement does not directly relate to smoking cessation. Staying hydrated is important for overall health, but it is not a specific strategy for quitting smoking. Choices A, B, and D are all relevant to smoking cessation. A: Finding an activity to keep hands busy can help distract from the urge to smoke. B: Keeping snacks on hand can help manage cravings and replace the oral fixation of smoking. D: Making a list of reasons for quitting can provide motivation and remind the client of their goals.