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A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?
- A. Initiate oxygen therapy at 2 liters per minute via nasal cannula.
- B. Place the client in a high-Fowler's position.
- C. Notify the healthcare provider.
- D. Document the finding in the client's medical record.
Correct Answer: A
Rationale: The correct answer is A: Initiate oxygen therapy at 2 liters per minute via nasal cannula. Oxygen saturation of 88% indicates hypoxemia and requires immediate intervention. Providing supplemental oxygen via nasal cannula will help improve oxygenation. Placing the client in high-Fowler's position may help with ventilation but addressing hypoxemia is the priority. Notifying the healthcare provider is important but immediate intervention is necessary. Documenting the finding is important but should not delay providing oxygen therapy.
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A client diagnosed with a new onset of diabetes requires instruction on how to use a glucometer and self-administer insulin. What information will you need to gather in the learner assessment?
- A. Current knowledge level,preferred learning style and readiness to learn.
- B. Only current knowledge level.
- C. Only preferred learning style.
- D. Only readiness to learn.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while withdrawing the catheter
- B. Preoxygenating the client before suctioning
- C. Suctioning up to three times if necessary
- D. Suctioning for a duration of 10 to 15 seconds each time
Correct Answer: A
Rationale: The correct answer is A. When suctioning a tracheostomy, the student should not apply suction while withdrawing the catheter to prevent mucosal damage. The correct technique involves inserting the catheter without applying suction, then withdrawing it while applying suction. This helps to clear secretions effectively without causing trauma. Choices B, C, and D are incorrect. Preoxygenating the client is a recommended practice to prevent hypoxemia during suctioning. Suctioning up to three times if necessary and suctioning for 10-15 seconds each time are appropriate techniques to clear secretions effectively without causing harm.
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
- A. Notify the operating room of a potential emergency case.
- B. No action is required at this time; this pulsation can be a normal finding in some clients.
- C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
- D. Stay with the client and ask someone else to contact the provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately.
Rationale:
1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel.
2. Immediate provider notification is crucial to prevent potential complications.
3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise.
4. Contacting the provider promptly ensures timely intervention and appropriate next steps.
Summary:
A: Notifying the operating room is premature and unnecessary at this point.
B: Pulsation may not always be normal and warrants immediate action.
C: Removing the tube without professional guidance can be harmful to the client.
What are four basic characteristics of culture?
- A. Ever-present,shared by all members expected by all members adapted to individuals
- B. Dynamic,not always shared by all members
- C. adapted to specific conditions
- D. learned by communication and imitation
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who is interested in smoking cessation receives teaching from a nurse. Which statements should the nurse include in this teaching? (Select ONE that does not apply)
- A. Find an activity that you enjoy and that will keep your hands busy.
- B. Keep healthy snacks on hand to nibble on.
- C. Identify reasons for quitting smoking.
- D. Make a list of reasons for quitting smoking.
Correct Answer: C
Rationale: The correct answer is C: Identify reasons for quitting smoking. This should not be included in the teaching because the client should already have identified their reasons for quitting before receiving the teaching. The client should have a clear understanding of why they want to quit smoking before seeking help. Choices A and B are correct as they provide practical tips to distract from smoking and avoid unhealthy behaviors. Choice D is also correct as making a list of reasons can help reinforce motivation.