Nokea
List the order for the actions that you must perform.
- A. Perform the chin lift or jaw thrust maneuver
- B. Establish unresponsiveness
- C. Initiate cardiopulmonary resuscitation (CPR)
- D. Call for help and activate the code team
Correct Answer: B
Rationale: Establishing unresponsiveness is the first step in assessing the patient's condition.
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In assisting clients with vertigo and balance problems, which team members (RN, LPN/LVN, MD, physical therapist, nursing assistant), working under appropriate supervision, should be assigned to fulfill each task?
- A. Assess and identify the etiology of vertigo.
- B. Assist the client in routine position change and ambulation.
- C. Administer antivertigo agents, such as meclizine (Antivert).
- D. Obtain informed consent for a labyrinthectomy.
Correct Answer: A
Rationale: Assessment and identification of the etiology of vertigo require advanced clinical judgment, making this task appropriate for an RN or MD.
Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
List at least four factors in this situation that contribute to health disparities.
- A. Geographic isolation (living 'up the mountain')
- B. Limited access to healthcare (refusal of medical care)
- C. Low socioeconomic status (barely making a living)
- D. Lack of social support (children rarely visit)
Correct Answer: D
Rationale: Health disparities are influenced by geographic isolation, lack of access to healthcare, low socioeconomic status, and lack of social support. These factors collectively exacerbate her condition.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Preoxygenating the client with 100% oxygen for up to 3 minutes helps prevent hypoxia during suctioning.
2. COPD patients are at higher risk for hypoxia due to impaired gas exchange.
3. Preoxygenation helps maintain oxygen saturation levels and reduces the risk of complications.
4. This action supports safe and effective nasotracheal suctioning in clients with COPD and an artificial airway.
Summary:
- Option A: Performing suctioning for up to four passes can increase the risk of hypoxia and mucosal damage.
- Option B: Applying suction to the catheter during advancement can cause trauma and increase the risk of infection.
- Option D: Limiting each suction pass to 25 seconds may not provide adequate time for effective suctioning in clients with COPD and artificial airways.
Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient’s husband and two grown children are arguing at the bedside about where the patient’s funeral should be held. What should the nurse do first?
- A. Ask the family members to leave the room if they are going to argue.
- B. Take the family members aside and explain that the patient may be able to hear them.
- C. Tell the family members that this decision is premature because the patient has not yet died.
- D. Remind the family that this should be the patient’s decision and to ask her if she regains consciousness.
Correct Answer: B
Rationale: The patient may still be able to hear even if unresponsive, so the nurse should gently remind the family of this to maintain respect for the patient's dignity and provide emotional support.