Nokea
A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?
- A. Impaired physical mobility
- B. Ineffective breathing pattern
- C. Impaired skin integrity
- D. Risk for infection
Correct Answer: B
Rationale: The correct answer is B: Ineffective breathing pattern. In late-stage ALS, respiratory muscles weaken, leading to breathing difficulties. Priority is given to maintaining adequate oxygenation and ventilation. Impaired physical mobility (choice A) is important but not the highest priority. Impaired skin integrity (choice C) and risk for infection (choice D) may result from immobility but are secondary to the critical issue of breathing in this scenario.
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A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct Answer: C
Rationale: The correct answer is C: Check the client's oxygen saturation level. This is the first action the nurse should take to assess the effectiveness of the current oxygen therapy and determine the client's oxygenation status. A: Increasing the oxygen flow rate without assessing the client's oxygen saturation level may lead to potential oxygen toxicity. B: Instructing the client to breathe deeply and cough may not address the underlying issue of hypoxemia. D: Placing the client in a high-Fowler's position may help with breathing but does not address the immediate concern of the client's difficulty breathing. Checking the oxygen saturation level provides crucial information for appropriate interventions.
The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
- A. Administer an antiemetic before meals
- B. Provide frequent mouth care
- C. Encourage small, frequent meals
- D. Offer clear liquids
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic before meals. Administering an antiemetic before meals helps prevent and manage nausea associated with chemotherapy by blocking receptors that trigger nausea and vomiting. This intervention targets the root cause of the symptom. Providing frequent mouth care (B) may help with taste changes but does not directly address nausea. Encouraging small, frequent meals (C) and offering clear liquids (D) may be helpful for some clients, but they do not specifically target nausea caused by chemotherapy.
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? This question is crucial because seizures can be a common symptom of a brain tumor. By asking about seizures, the nurse can gather important information about the client's condition and potential complications. Seizures can also indicate the location and size of the tumor.
A: When did your symptoms first begin? This question is important, but seizures are more specific to brain tumor assessment.
B: Can you describe the pain and how it feels? Pain can vary and may not always be present with a brain tumor.
C: Do you have any changes in vision? Vision changes can occur but may not be as indicative of a brain tumor as seizures.
In summary, asking about seizures is crucial for immediate assessment and management of a client with a brain tumor, as it can provide valuable insight into the client's condition.
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
- A. Daily intake and output
- B. Skin turgor
- C. Daily weight
- D. Vital signs every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.