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Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of high levels of oxygen for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. High levels of oxygen over a prolonged period can lead to oxygen toxicity.
2. Oxygen toxicity can cause lung damage and respiratory distress.
3. To prevent oxygen toxicity, it is crucial to monitor and limit the duration and amount of oxygen administered.
4. Therefore, avoiding the administration of high levels of oxygen for extended periods is the most effective intervention to prevent oxygen toxicity.
Summary of other choices:
B: Administering a sedative does not address the root cause of oxygen toxicity and can mask symptoms.
C: Removing the nasal cannula at night can lead to hypoxia and is not a safe practice.
D: Running oxygen through a hydration source does not prevent oxygen toxicity and is not a recognized intervention.
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A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition.
Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition.
Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies.
Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy.
Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.
Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.
Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.
Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
- A. Wear long-sleeved clothing when outdoors
- B. Report the onset of sore throat
- C. Eat plenty of potassium-rich food
- D. Change the position slowly
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up.
A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned.
B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers.
C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension.
In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)
- A. Increased heart rate
- B. Visual disturbances
- C. Presence of uremic frost
- D. Decreased mentation
Correct Answer: C
Rationale: The correct answer is C: Presence of uremic frost. HHNS is characterized by severe hyperglycemia leading to osmotic diuresis and dehydration, not uremia. A: Increased heart rate is a non-specific sign of stress. B: Visual disturbances can be seen in diabetic retinopathy but are not specific to HHNS. D: Decreased mentation is common in HHNS due to severe dehydration and hyperglycemia leading to altered mental status.