Nokea
Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse?
- A. Administer oxygen.
- B. Administer bronchodilators.
- C. Administer antianxiety agents.
- D. Use any methods that make the patient more comfortable.
Correct Answer: D
Rationale: Comfort measures tailored to the individual patient’s needs are prioritized in palliative care, ensuring the patient feels supported and comfortable.
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What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
- A. Observing for confusion
- B. Auscultating breath sounds
- C. Confirming the gag reflex
- D. Measuring blood pressure
Correct Answer: C
Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.
A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
List in order the steps that are required to perform this function.
- A. Obtain an order for a chest x-ray to document tube placement
- B. Secure the tube in place
- C. Auscultate the chest during assisted ventilation
- D. Confirm that the breath sounds are equal and bilateral
Correct Answer: B
Rationale: Securing the tube ensures it remains in place during further assessments.
Nurses who rotate shifts or work nights are at risk for developing shift work sleep disorder characterized by insomnia, sleepiness, and fatigue. Identify at least three negative implications for the nurse.
- A. Increased risk of errors
- B. Decreased job satisfaction
- C. Higher likelihood of accidents
- D. Sleep just before going to work
Correct Answer: A
Rationale: The correct answers are A, B, and C. Shift work sleep disorder increases the risk of errors, reduces job satisfaction, and raises the likelihood of accidents due to impaired alertness.
A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?
- A. Severe dyspnea
- B. Nausea
- C. Decreased level of consciousness
- D. Headache
Correct Answer: B
Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.