Nokea
An adult client is receiving oxygen at 6 L/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?
- A. The water cools the oxygen and makes it more comfortable.
- B. Oxygen is very drying to tissues; the water humidifies it.
- C. The water prevents fires when oxygen is in use.
- D. The water helps to prevent infections from developing in the tubing.
Correct Answer: B
Rationale: Bubbling water in oxygen delivery systems humidifies the oxygen, preventing mucosal drying. It doesn't cool oxygen, prevent fires, or reduce infections.
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During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Discusses the client's need for a nutrient-rich, high-calorie diet with the dietician
- B. Documents the impaired skin as an unstageable pressure injury in the client's medical record
- C. Gently cleanses the impaired skin with normal saline and pats the area dry with gauze
- D. Places a hydrophilic dressing over the impaired skin after performing wound care
- E. Repositions the client frequently and avoids putting pressure on the impaired skin
Correct Answer: A,C,D,E
Rationale: A nutrient-rich diet (A) supports wound healing. Cleansing with saline (C) prevents infection. A hydrophilic dressing (D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.
A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
- A. Acknowledging the presence of the pain
- B. Elevating the stump on a pillow
- C. Applying a transcutaneous nerve stimulator unit (TENS)
- D. Rewrapping the stump
Correct Answer: C
Rationale: Applying a TENS unit can help relieve phantom limb pain by stimulating nerves and reducing pain signals. Acknowledging the pain is supportive but does not directly relieve it. Elevating the stump may help with swelling but not specifically phantom pain. Rewrapping the stump may provide comfort but is less effective than TENS for pain relief.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
- A. Report the behavior to the head nurse
- B. Report the behavior if it happens again
- C. Interrupt the conversation in the elevator
- D. Speak to the staff member when he/she gets off the elevator
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.