Nokea
A patient with a second-degree burn has a greater risk for
- A. Constipation.
- B. Infection.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Burns disrupt skin integrity, increasing infection risk.
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When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
- A. Administer prescribed antibiotics on time.
- B. Encourage the client to use a tissue when coughing.
- C. Place the client in a private room.
- D. Perform hand hygiene before and after client contact.
Correct Answer: D
Rationale: The correct answer is D because performing hand hygiene before and after client contact is crucial in preventing the spread of infection in pneumonia. This intervention helps in reducing the transmission of infectious agents from one client to another and from surfaces to clients. It is a fundamental infection control measure that minimizes the risk of spreading pathogens. Option A is important for treating the infection but does not directly prevent its spread. Option B is a good practice to contain respiratory secretions but may not be as effective as hand hygiene. Option C isolates the client but does not address the primary mode of transmission through contaminated hands.
After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?
- A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
- B. Client's HR is 55 beats/min. Nurse withholds pain medication.
- C. Client has reduced breath sounds. Nurse calls the physician immediately.
- D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.
Correct Answer: C
Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment.
Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Assess the client's vital signs including oxygen saturation.
- C. Notify the Rapid Response Team immediately.
- D. Place the client in a high Fowler's position.
Correct Answer: D
Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress.
Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.
You are reviewing the drug list of an elderly client who is on several medications prescribed by different specialists for various health problems. The client reports 'lately there has been a roaring sound in my ears.' You notify the prescriber of which medication?
- A. gentamicin sulfate (Garamycin)
- B. metoprolol (Lopressor)
- C. amoxicillin (Amoxil)
- D. warfarin (Coumadin)
Correct Answer: A
Rationale: Gentamicin is an ototoxic medication that can cause tinnitus or hearing loss, warranting notification of the prescriber.
Which factors predispose a client to hypoxia during the immediate postoperative period?
- A. Pooling of secretions in the lungs
- B. Fluid and electrolyte loss
- C. Physical and psychological trauma
- D. Increased mobility
Correct Answer: A
Rationale: The correct answer is A because pooled secretions can obstruct airways, leading to hypoxia.