Nokea
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
- A. This medication is given to treat infection.
- B. This medication is given to facilitate ventilation.
- C. This medication is given to decrease inflammation.
- D. This medication is given to reduce anxiety.
Correct Answer: B
Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.
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A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
- B. ''I will lie on my back with my knees bent.''
- C. ''I will rest my hand over my abdomen to create resistance.''
- D. ''I will take in a deep breath and hold it before exhaling.''
Correct Answer: D
Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.
When educating a client who experienced a pneumothorax, which of the following statements should the nurse use?
- A. Notify the provider if you experience weakness.
- B. You should be able to return to work in 1 week.
- C. You need to wear a mask when in crowded areas.
- D. Notify your provider if you experience a productive cough.
Correct Answer: D
Rationale: After experiencing a pneumothorax, it is crucial for the client to be educated on potential complications. A productive cough can indicate infection or another issue, requiring prompt medical attention. Weakness, returning to work, and wearing a mask in crowded areas are important considerations but not as critical as monitoring for respiratory symptoms post-pneumothorax.
A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?
- A. There are portable oxygen delivery systems that you can take with you.
- B. When you go out, you can remove the oxygen and then reapply it when you get home.
- C. You probably will not be able to go out as much as you used to.
- D. Home health services will come to see you so you will not need to get out.
Correct Answer: A
Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.
A healthcare professional in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the professional not expect?
- A. Bradycardia
- B. Cyanosis
- C. Hypotension
- D. Dyspnea
Correct Answer: A
Rationale: Bradycardia is not typically associated with a flail chest. Flail chest is characterized by paradoxical chest wall movement, respiratory distress, and hypoxia, but it does not usually cause bradycardia. The other options, such as cyanosis (bluish discoloration of the skin due to poor oxygenation), hypotension (low blood pressure), and dyspnea (difficulty breathing), are commonly seen in patients with flail chest due to the underlying respiratory compromise.
When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?
- A. Air should be instilled into the monitoring system after the procedure.
- B. The client should be positioned on the left side after the procedure.
- C. The transducer should be level with the second intercostal space after the line is placed.
- D. A chest x-ray is needed to verify placement after the procedure.
Correct Answer: D
Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.