Nokea
During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct Answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
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When caring for a client on pressure support ventilation (PSV), which statement by the nurse indicates an understanding of PSV?
- A. It keeps the alveoli open and prevents atelectasis.
- B. It allows preset pressure delivered during spontaneous ventilation.
- C. It guarantees minimal minute ventilator.
- D. It delivers a preset ventilatory rate and tidal volume to the client.
Correct Answer: B
Rationale: Pressure support ventilation (PSV) is a mode that delivers a preset pressure when the client initiates a breath. This support helps the client to breathe spontaneously by reducing the work of breathing. The correct statement indicating an understanding of PSV is that it allows preset pressure to be delivered during spontaneous ventilation, as it assists the client's efforts without controlling the rate or volume of each breath.
A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?
- A. Client who has dysphagia
- B. Client who has AIDS
- C. Client who was vaccinated for pneumococcus and influenza 6 months ago
- D. Client who has a closed head injury and is receiving ventilation
Correct Answer: C
Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.
During discharge teaching, a client informs the nurse about a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?
- A. I will decrease my fluid intake while taking this medication.
- B. I will expect to have black, tarry stools.
- C. I will take my medication with meals.
- D. I will monitor for weight loss while on this medication.
Correct Answer: C
Rationale: Taking prednisone with meals can help reduce the risk of gastrointestinal upset and irritation. It is important for the client to understand how to take the medication correctly to maximize its effectiveness and minimize potential side effects. Monitoring for weight loss or changes in stools may be important but does not directly relate to the administration of the medication with meals.
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
- A. Apply a vest restraint if self-extubation is attempted.
- B. Monitor ventilator settings every 8 hours.
- C. Document tube placement in centimeters at the angle of the jaw.
- D. Assess breath sounds every 1 to 2 hours.
Correct Answer: D
Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.
A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct Answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.