Nokea
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
- A. Use a laryngoscope to check for a foreign body lodged in the airway.
- B. Reposition the head to ensure that the airway is properly opened.
- C. Turn the client to the side and administer three back blows.
- D. Perform a finger sweep of the mouth to clear any obstructions.
Correct Answer: B
Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.
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A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
- A. He visits his diabetic brother who just had surgery to amputate an infected foot.
- B. He is provided with the most current information about the dangers of untreated diabetes.
- C. He comments on the community service announcements about preventing complications associated with diabetes.
- D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.
Correct Answer: A
Rationale: According to the Health Belief Model, the most effective event to increase compliance with the prescribed diet for a middle-aged male client with diabetes is experiencing a significant consequence related to the disease. In this case, visiting his diabetic brother who just had surgery to amputate an infected foot would serve as a strong 'cue to action,' increasing the client's perceived seriousness of the disease. This event is likely to have a more immediate and impactful effect on the client than other options. Option B provides valuable information but may not have the same personal and emotional impact as witnessing a severe consequence firsthand. Option C involves indirect exposure to prevention messages, which might not be as compelling as a direct experience. Option D, while supportive, does not present a direct consequence of non-compliance like option A does.
What discharge instruction is most important for a client after a kidney transplant?
- A. Weigh weekly.
- B. Report symptoms of secondary Candidiasis.
- C. Use daily reminders to take immunosuppressants.
- D. Stop cigarette smoking.
Correct Answer: C
Rationale: After a kidney transplant, it is crucial for the client to adhere to the prescribed immunosuppressive therapy to prevent organ rejection. The client must take medications like corticosteroids and azathioprine (Imuran) regularly for the rest of their life. Using daily reminders is essential to ensure compliance with the medication regimen, as missing doses can increase the risk of organ rejection. Weighing weekly, reporting symptoms of secondary Candidiasis, and stopping cigarette smoking are important aspects of post-transplant care but may not be as critical as ensuring proper intake of immunosuppressants to prevent rejection.
When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?
- A. Recommend that the client carry suction equipment at all times.
- B. Instruct the client to have writing materials with them at all times.
- C. Tell the client to carry a medic alert card stating that they are a total neck breather.
- D. Tell the client not to travel alone.
Correct Answer: C
Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide?
- A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
- B. Infrequent intercourse results in the vaginal tissues losing their elasticity.
- C. Dehydration from inadequate fluid intake causes vulva tissue dryness.
- D. Lack of adequate stimulation is the most common reason for dyspareunia.
Correct Answer: A
Rationale: Estrogen deficiency in postmenopausal clients leads to a decrease in the moisture-secreting capacity of vaginal cells. This results in vaginal tissues becoming thinner, drier, and smoother, which reduces vaginal stretching and contributes to discomfort during intercourse. Choice B is incorrect because the primary reason for discomfort is not infrequent intercourse but rather physiological changes due to estrogen deficiency. Choice C is incorrect as dehydration may cause dryness but is not the primary reason for discomfort in this scenario. Choice D is incorrect as lack of stimulation is not the most common reason for dyspareunia in postmenopausal clients; estrogen deficiency is the key factor.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?
- A. Administer 20 mEq of potassium chloride.
- B. Initiate continuous cardiac monitoring.
- C. Arrange a consultation with the dietitian.
- D. Educate about the side effects of diuretics.
Correct Answer: B
Rationale: Hypokalemia, defined as a serum potassium level below the normal range of 3.5 to 5 mEq/L, can lead to changes in myocardial irritability and ECG waveform, potentially causing life-threatening dysrhythmias. Therefore, the priority action for the nurse is to initiate continuous cardiac monitoring to promptly detect any abnormal heart rhythms or ventricular ectopy. This monitoring is crucial for assessing the impact of potassium replacement therapy on the cardiac rhythm and ensuring the safety of the client. While administering potassium chloride is important for correcting the hypokalemia, it should occur after cardiac monitoring is in place. Consulting with a dietitian and educating about diuretic side effects are relevant aspects of care but are not the immediate priority in this situation where cardiac monitoring takes precedence for timely intervention.