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A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?
- A. Continue to suction.
- B. Notify the physician immediately.
- C. Stop the procedure and reoxygenate the client.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: C
Rationale: The correct answer is C: Stop the procedure and reoxygenate the client. When the nurse notes a decreasing heart rate during suctioning, it could indicate that the client is experiencing hypoxia. Stopping the procedure and providing additional oxygenation is crucial to prevent further complications such as bradycardia or cardiac arrest. Continuing to suction (choice A) can worsen the hypoxia. Notifying the physician immediately (choice B) may cause a delay in addressing the immediate issue. Limiting suction to 15 seconds (choice D) does not address the primary concern of hypoxia and decreasing heart rate.
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A home health nurse is visiting a new client who uses oxygen in the home. For which factors doesn't the nurse assess when determining if the client is using the oxygen safely?
- A. The client does not allow smoking in the house.
- B. Electrical cords are in good working order.
- C. Flammable liquids are stored in the garage.
- D. Household light bulbs are the fluorescent type.
Correct Answer: D
Rationale: The correct answer is D because household light bulbs being fluorescent type is unrelated to the safe use of oxygen. The nurse should assess factors directly related to oxygen safety, such as smoking restrictions, electrical cord condition, and proper storage of flammable materials. Fluorescent light bulbs do not pose a significant risk in relation to oxygen safety.
Which class of drugs often inhibits carbonic anhydrase and is used for certain medical conditions?
- A. Antibiotics
- B. Antihistamines
- C. Carbonic anhydrase inhibitors
- D. Antidepressants
Correct Answer: C
Rationale: The correct answer is C: Carbonic anhydrase inhibitors. These drugs inhibit the enzyme carbonic anhydrase, which plays a role in various physiological processes. They are used to treat conditions such as glaucoma, epilepsy, and altitude sickness. Antibiotics (A) target bacterial infections, antihistamines (B) relieve allergy symptoms, and antidepressants (D) treat depression, making them unrelated to carbonic anhydrase inhibition.
For which client(s) would you assign the nursing care to the new RN under your supervision? (Choose all that apply.)
- A. A 38-year-old client with moderate persistent asthma awaiting discharge
- B. A 63-year-old client with tracheostomy needing trach care every shift
- C. A 56-year-old client with lung cancer just returned from left lower lobectomy
- D. A 49-year-old new admission client with new diagnosis of esophageal cancer
Correct Answer: D
Rationale: The correct answer includes A and D. Assigning care for clients with moderate persistent asthma (A) and a new diagnosis of esophageal cancer (D) is appropriate for a new RN under supervision. Clients requiring tracheostomy care (B) or post-lobectomy recovery (C) involve complex care unsuitable for a new RN.
A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
- A. Activity intolerance related to fatigue.
- B. Anxiety related to actual threat to health status.
- C. Risk for infection related to retained secretions.
- D. Impaired gas exchange related to airflow obstruction.
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to airflow obstruction. This is the most important nursing diagnosis for a patient with chronic obstructive pulmonary disease because impaired gas exchange directly impacts the patient's ability to breathe and obtain oxygen. Addressing this issue is crucial in managing the patient's condition and preventing further complications.
A: Activity intolerance related to fatigue may be a concern for the patient, but it is secondary to the primary issue of impaired gas exchange.
B: Anxiety related to actual threat to health status is important to address, but it is not the most critical nursing diagnosis for this patient.
C: Risk for infection related to retained secretions is a valid concern, but it is not as immediate and directly life-threatening as impaired gas exchange in a patient with chronic obstructive pulmonary disease.
A 17-year-old male is admitted following an automobile accident. He is very anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of?
- A. Hemothorax
- B. Flail chest
- C. Atelectasis
- D. Pleural effusion
Correct Answer: B
Rationale: The correct answer is B: Flail chest. Flail chest is characterized by paradoxical movement of a segment of the chest wall due to multiple rib fractures. In this case, the left chest wall moving in during inspiration and out during expiration indicates this paradoxical movement. This leads to ineffective breathing, causing dyspnea and anxiety. Hemothorax (A) is accumulation of blood in the pleural cavity, not associated with chest wall movement. Atelectasis (C) is collapse of lung tissue, not associated with chest wall movement. Pleural effusion (D) is accumulation of fluid in the pleural space, also not associated with paradoxical chest wall movement.