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If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
- A. Try using an ambu bag.
- B. Decrease the rate of compressions.
- C. Intubate the client.
- D. Reposition the airway.
Correct Answer: D
Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.
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During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
- A. Pulse.
- B. Respirations.
- C. Blood pressure.
- D. Temperature.
Correct Answer: C
Rationale: Controlling blood pressure is the primary goal post-thrombolytic therapy to prevent hemorrhagic transformation. Pulse, respirations, and temperature are monitored but are secondary.
A client returned to the recovery room after a dilatation and curettage has the postoperative medication orders shown in the chart. What should the nurse do next?
- A. Ask the client to rate the intensity of her painon a scale of 1 to 10 and administer the analgesia according to the intensity of the pain.
- B. Administer the Demerol fi rst because the client had surgery today.
- C. Administer the Tylenol #3 fi rst, and if it does not relieve the pain in 2 hours, administer the Demerol.
- D. Administer the Motrin fi rst and if it does not relieve the pain, administer the Demerol.
Correct Answer: A
Rationale: The nurse must fi rst assess the intensity of the client’s pain before selecting the correct analgesia. A high score would necessitate administering the meperidine (Demerol). If the intensity rating is low, an oral analgesic would be appropriate. If acetaminophen (Tylenol #3) is given without assessing the intensity of the client’s pain, the nurse must then wait 4 hours before administering another analgesic
The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:
- A. Start attending church or chapel services once a week.
- B. Call a chaplain and set up an appointment for spiritual guidance.
- C. Reflect on past accomplishments.
- D. Participate in spiritual activities of the client's choice.
Correct Answer: D
Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?
- A. I will be able to have sexual intercourse until the urinary catheter is removed.'
- B. I can participate in sexual activity but might not experience orgasm.'
- C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
- D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B
Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.