Nokea
After the client receives the weekly injection, which nursing instruction is essential?
- A. Take a couple of aspirin before leaving.
- B. Wait at least 30 minutes before leaving.
- C. Make sure someone else drives the car.
- D. Avoid getting the injection site wet.
Correct Answer: B
Rationale: Clients must wait at least 30 minutes after an allergy injection to monitor for potential allergic reactions, such as anaphylaxis.
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The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
- A. Assess respiratory rate and depth.
- B. Provide for adequate rest period.
- C. Administer oxygen as prescribed.
- D. Teach slow abdominal breathing.
Correct Answer: C
Rationale: Administering oxygen as prescribed (C) is the priority for bacterial pneumonia to address hypoxemia, a common issue due to impaired gas exchange. Assessing respiratory rate (A) is important but secondary to ensuring oxygenation. Rest (B) and breathing techniques (D) support recovery but are not the first priority.
The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement?
- A. Praise the UAP because this prevents the client from tripping on the oxygen tubing.
- B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
- C. Explain to the UAP in front of the client oxygen must be left in place at all times.
- D. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Correct Answer: B
Rationale: COPD clients need continuous oxygen; replacing it (B) corrects the error safely. Praising (A) is incorrect, explaining in front of client (C) is unprofessional, and escalating (D) is premature.
An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
- A. Use a sterile tube each time and suction for 30 seconds
- B. Use sterile technique and turn the suction off as the catheter is introduced
- C. Use clean technique and suction for 10 seconds
- D. Discard the catheter at the end of every shift
Correct Answer: B
Rationale: Suctioning should use sterile technique, with suction off during insertion and applied intermittently for no more than 10 seconds to prevent hypoxia and trauma.
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: This medication can be very toxic to the ears (cranial nerve 8). Therefore, it is alarming if the patient reports ringing in their ears, which could represent ototoxicity.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.