Nokea
After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?
- A. Have the client take slow deep breaths in through their mouth and out through their nose.
- B. Post signs indicating that oxygen is in use on the client's door and in their room
- C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
- D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
Correct Answer: A
Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.
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The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?
- A. Fluticasone (Flovent)
- B. Salmeterol (Serevent)
- C. Theophylline (Theodur)
- D. Albuterol (Atrovent)
Correct Answer: D
Rationale: The correct answer is Albuterol (Atrovent) because it is a rapid-acting bronchodilator, essential for a client experiencing wheezing and difficulty breathing. Albuterol acts quickly, dilating the airways and providing immediate relief in cases of respiratory distress. Fluticasone (Flovent) and Salmeterol (Serevent) are maintenance medications for long-term asthma control, not suitable for acute situations described. Theophylline (Theodur) is a bronchodilator but with a slower onset compared to Albuterol, making it less appropriate for a client in immediate distress.
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
- A. Facial flushing
- B. A complaint of chest heaviness
- C. Heart rate increase of 10 beats/min
- D. Systolic blood pressure increase of 10 mm Hg
Correct Answer: B
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
Which is an example of a sentinel event?
- A. The terminally ill client is referred to hospice and dies 3 months later.
- B. A client receives an unordered mammogram which reveals a small cyst.
- C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
- D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.
Correct Answer: D
Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
- A. Weight gain
- B. Fatigue
- C. Bloody sputum
- D. Diaphoresis during sleep
Correct Answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.