Nokea
A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?
- A. Administer oxygen via face mask.
- B. Elevate the client's legs.
- C. Prepare the client for immediate surgery.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.
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What is the most effective way to communicate with a patient who has expressive aphasia?
- A. Asking yes or no questions
- B. Encouraging the patient to write responses
- C. Using picture boards or communication cards
- D. Speaking slowly and clearly
Correct Answer: C
Rationale: The most effective way to communicate with a patient who has expressive aphasia is by using picture boards or communication cards. These tools allow patients to convey their needs and responses more effectively when they struggle to speak. Using picture boards or communication cards (Choice C) is preferred as it provides a visual aid to support communication. Asking yes or no questions (Choice A) may limit the patient's ability to express themselves fully. Encouraging the patient to write responses (Choice B) may not be suitable if the patient also has difficulty writing due to the aphasia. While speaking slowly and clearly (Choice D) is important, it may not be sufficient to overcome the communication challenges faced by patients with expressive aphasia.
The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?
- A. Explain how to use a communication board
- B. Document progress in the use of the communication board
- C. Encourage voiding by assisting the client to the bedside commode
- D. Establish a bladder training schedule and methods
Correct Answer: C
Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.
Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?
- A. Withhold the medication and notify the charge nurse
- B. Give the medication and document the heart rate
- C. Withhold the medication until the next scheduled dose
- D. Request the charge nurse to administer the medication
Correct Answer: B
Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.
Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?
- A. Performing oral care with chlorhexidine
- B. Elevating the head of the bed to 30-45 degrees
- C. Administering prophylactic antibiotics
- D. Changing the ventilator circuit daily
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.
The UAP reports to the PN that a client refused to bathe for the third consecutive day. Which action is best for the PN to take?
- A. Explain the importance of good hygiene to the client
- B. Ask family members to encourage the client to bathe
- C. Reschedule the bath for the following day
- D. Ask the client why the bath was refused
Correct Answer: D
Rationale: The best action for the PN to take when a client refuses to bathe is to ask the client why the bath was refused. Understanding the client's reasons for refusing a bath is crucial as it helps to address any underlying issues, such as fear, discomfort, or physical limitations. By communicating directly with the client, the PN can provide appropriate care tailored to the client's needs. Choices A, B, and C do not directly address the root cause of the refusal and may not effectively resolve the issue.