Nokea
During the prodromal stage of an infection, which is the priority nursing intervention?
- A. Develop a plan for gradually increasing activity and mobility.
- B. Begin discharge planning and teaching.
- C. Implement precautions to prevent disease transmission.
- D. Offer the client frequent fluids and ice chips.
Correct Answer: C
Rationale: Precautions prevent infection spread.
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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
History and physical
The client is a 69-year-old male with a history of emphysema and hypertension. He presented to the emergency room with shortness of breath and reporting chest pain. He was admitted to the medical floor for cardiac exam and monitoring.
Nurses notes :
1930
The client was alert and oriented when he first came on the unit. Now the client is confused and asking where he is at. His oxygen mask was found on the floor. His lips are blue.
Vital signs
. Heart rate 100 beats/minute
Respiratory rate 29 breaths/minute
. Blood pressure 155/89 mm Hg
Oxygen saturation 75% on room air
Orders:
1845
Admit to medical floor
. Clear liquid diet
12-lead electrocardiogram (ECG)
Apply oxygen 10 L/minute non-rebreather, titrate to keep oxygen saturation greater than 88%
.Send specimens to the laboratory for a blood gas, cardiac enzymes, chemistry, and complete blood count.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Replace the non rebreather mask;Perform oropharyngeal suctioning;Change the oxygen delivery method;Increase the flow of oxygen to 12L;Use a manual resuscitation bag to provide breaths
- B. Obstructed airway;Hypoxia;Pulmonary edema;Apnea
- C. Color and consistency of mucus;Oxygen saturation;Level of consciousness;Skin color;Gag reflex
Correct Answer:
Rationale: Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.