Nokea
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.
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A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.
When developing a teaching plan for a patient, what should the nurse recognize?
- A. Frustration will enhance the patient’s desire to learn
- B. Only formal teaching plans have been found to be effective
- C. The patient’s previous educational experiences do not influence his learning
- D. The patient must accept responsibility for compliance with his therapeutic regimen
Correct Answer: D
Rationale: Patient responsibility is essential for adherence to therapeutic regimens.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
How should the nurse respond to Mrs. West’s statement, “Oh well, I have already lived my life anyway.”
- A. “Oh, you have nothing to worry about Mrs. West. We’re going to take good care of you.”
- B. “You feel that your life is ending, Mrs. West? Can you tell me more about your feelings?”
- C. “Your doctor is one of the best and our surgical staff is excellent.”
- D. “The x-rays indicate that your tumor is accessible and the surgery will cure your problem.”
Correct Answer: B
Rationale: Encouraging the patient to express feelings fosters trust and understanding.