Nokea
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?
- A. Preparing to assist with intubating the patient
- B. Setting up oxygen at 5 L/minute by nasal cannula
- C. Performing deep suctioning
- D. Setting up a nebulizer to administer corticosteroids
Correct Answer: A
Rationale: A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.
You may also like to solve these questions
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
- A. Administer intradermal injections into the childrens inner forearms
- B. Administer intramuscular injections into each childs vastus lateralis
- C. Administer a subcutaneous injection into each childs umbilical area
- D. Administer a subcutaneous injection at a 45-degree angle into each childs deltoid
Correct Answer: A
Rationale: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
- A. A resident who suffered a severe stroke several weeks ago
- B. A resident with mid-stage Alzheimers disease
- C. A 92-year-old resident who needs extensive help with ADLs
- D. A resident with severe and deforming rheumatoid arthritis
Correct Answer: A
Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances?
- A. Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air
- B. Wear protective attire and devices when working with a toxic substance
- C. Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins
- D. Always wear a disposable paper face mask when you are working with inhalable toxins
Correct Answer: B
Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
- A. Pneumothorax
- B. Anxiety
- C. Acute bronchitis
- D. Aspiration
Correct Answer: A
Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?
- A. The importance of adhering closely to the prescribed medication regimen
- B. The fact that the disease is a lifelong, chronic condition that will affect ADLs
- C. The fact that TB is self-limiting, but can take up to 2 years to resolve
- D. The need to work closely with the occupational and physical therapists
Correct Answer: A
Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.