Nokea
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions
- B. We would give you oxygen through a tube in your nose
- C. You would give you oxygen through a tube in your nose.
- D. We would insert a breathing tube while we evaluate your condition
Correct Answer: B
Rationale: We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.
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Upon assessment,the nurse notes that a client has dyspnea crackles in both lung bases and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?
- A. Ineffective Breathing Pattern
- B. Anxiety
- C. Ineffective Airway Clearance
- D. Impaired Gas Exchange
Correct Answer: C
Rationale: Crackles in both lung bases (C) indicate fluid or mucus in the airways supporting Ineffective Airway Clearance where the client struggles to clear secretions leading to dyspnea and fatigue. Ineffective Breathing Pattern (A) focuses on altered rhythm or depth not crackles. Anxiety (B) lacks specific respiratory findings. Impaired Gas Exchange (D) relates to oxygenation deficits not primarily airway clearance making C the best-supported diagnosis.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
- A. Insert the suction catheter while the client is swallowing
- B. Apply intermittent suction when withdrawing the catheter.
- C. Place the catheter in a location that is clean and dry for later use.
- D. Hold the suction catheter with her clean, nondominant hand.
Correct Answer: B
Rationale: Apply intermittent suction when withdrawing the catheter. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. The nurse should insert the suction while the client is inhaling to avoid inserting into the esophagus, discard the suction catheter to eliminate the risk for infection, and the nurse should use her dominant hand with a sterile glove.
A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in
- A. Ventilation.
- B. Alveolar gas exchange.
- C. Transportation of oxygen and carbon dioxide.
- D. Systemic diffusion.
Correct Answer: A
Rationale: Atelectasis (collapsed alveoli) reduces lung compliance impairing ventilation (A) the movement of air into and out of the lungs. Alveolar gas exchange (B) is affected secondarily. Transportation (C) and systemic diffusion (D) are downstream processes not directly altered by atelectasis making A the primary alteration to anticipate.
When moving a client up in bed with the assistance of another caregiver, the nurse should:
- A. Elevate the head of the bed
- B. Have the client fold the arms across the chest
- C. Ask another nurse [incomplete]
- D. Maintain a pillow under the client's head
Correct Answer: D
Rationale: A pillow provides comfort and support. Elevating (A) hinders movement. Folding arms (B) isn’t standard. Asking another nurse (C) is unclear.
When planning care,for which client should the nurse include close observation for a decreased or absent cough reflex?
- A. The client with a nasal fracture
- B. The client with impairment of vagus nerve conduction
- C. The client with a sinus infection
- D. The client with reduction in respiratory membrane conduction
Correct Answer: B
Rationale: The cough reflex relies on vagus nerve (cranial nerve X) conduction to the medulla. Impairment of vagus nerve function (B) such as from spinal cord injury or CNS depression can decrease or eliminate the cough reflex increasing risks of aspiration and respiratory infections requiring close monitoring. Nasal fractures (A) and sinus infections (C) do not typically affect the cough reflex. Reduced respiratory membrane conduction (D) impacts gas exchange