Nokea
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma.
Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing.
Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes.
Summary:
A: Increasing oxygen flow does not directly address the issue of wheezes.
B: Encouraging coughing does not address the narrowing of airways seen with wheezes.
D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.
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What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?
- A. Label the catheter as an epidural access
- B. Assess the patient’s pain relief frequently
- C. Use sterile technique when caring for the catheter
- D. Monitor the patient’s level of consciousness (LOC)
Correct Answer: B
Rationale: The correct answers are B. All listed actions are essential for safe and effective care.
What should the nurse instruct Mr. Ross to withhold food and fluid for several hours until after fiberoptic bronchoscopy?
- A. Sputum returns to normal color and consistency
- B. Speech returns to the normal pattern
- C. Vital signs become stable
- D. Cough reflex is present
Correct Answer: D
Rationale: A functioning cough reflex prevents aspiration.
Prior to a cardiac catheterization, what is the most important action for the nurse to take?
- A. Ensure that the client has been NPO for 6 hours before the procedure.
- B. Administer pre-procedure medications as ordered.
- C. Verify that informed consent has been obtained.
- D. Assess the client for any allergies, especially to iodine or shellfish.
Correct Answer: D
Rationale: The correct answer is D: Assess the client for any allergies, especially to iodine or shellfish. This is crucial because contrast dye containing iodine is commonly used during cardiac catheterization, and a client with allergies to iodine or shellfish can have a severe allergic reaction. It is essential to identify allergies beforehand to prevent any potential adverse reactions during the procedure.
A: Ensuring NPO status is important for some procedures, but assessing for allergies is more critical to prevent life-threatening reactions.
B: Administering pre-procedure medications is important, but assessing for allergies takes precedence to avoid allergic reactions.
C: While obtaining informed consent is necessary, assessing for allergies is a crucial safety measure to prevent allergic reactions during the procedure.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?
- A. Decrease the heparin rate.
- B. Increase the heparin rate.
- C. No change to the heparin rate.
- D. Stop the heparin; start warfarin (Coumadin).
Correct Answer: B
Rationale: The correct answer is B: Increase the heparin rate. A PTT of 25 seconds indicates that the client's blood is not adequately anticoagulated, as the therapeutic range for PTT is typically around 60-80 seconds for heparin therapy. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired anticoagulant effect and prevent further clot formation.
Incorrect choices:
A: Decreasing the heparin rate would further decrease the anticoagulant effect, potentially putting the client at risk for thrombus progression.
C: No change to the heparin rate would not address the subtherapeutic PTT level and could lead to inadequate anticoagulation.
D: Stopping heparin and starting warfarin is not appropriate at this time as warfarin takes time to reach therapeutic levels, whereas heparin provides immediate anticoagulation for acute situations like a pulmonary embolism.