Nokea
Before suctioning, the nurse attaches a pulse oximeter to the client's finger. Which nursing actions are appropriate at this time? Select all that apply.
- A. Remove the client's fingernail polish.
- B. Place the sensor and receiver opposite to each other on the client's finger.
- C. Connect the cable to the oximeter.
- D. Set the SpO2 alarms between 95% and 100%.
- E. Notify the physician each time an alarm sounds.
- F. Relocate the spring-loaded sensor periodically.
Correct Answer: A, B, C, F
Rationale: Removing nail polish, positioning the sensor correctly, connecting the cable, and relocating the sensor periodically ensure accurate pulse oximetry readings.
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Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
- A. It produces greater blood oxygen levels.
- B. It is easier to breathe through the nose.
- C. The nares humidify, warm, and filter the air.
- D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Correct Answer: C
Rationale: The nares humidify, warm, and filter air, improving its quality for respiration.
The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement?
- A. Standard Precautions.
- B. Contact Precautions.
- C. Droplet Precautions.
- D. Airborne Precautions.
Correct Answer: D
Rationale: TB is transmitted via airborne droplets, requiring airborne precautions (D) with negative-pressure rooms. Standard (A), contact (B), and droplet (C) are insufficient.
After administering morphine sulfate (Roxanol) to the client, which of the following is most important for the nurse to assess?
- A. The rhythm of the heart
- B. Skin color and temperature
- C. Presence of bowel sounds
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Morphine can cause respiratory depression, so assessing the rate and depth of respirations is critical to ensure safety.