Nokea
The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?
- A. The ventilator rate is set at 14 breaths per minute.
- B. A manual resuscitation bag is at the client's bedside.
- C. The client's pulse oximeter reading is 85%.
- D. The ABG results are pH 7.4, PaO2 88, PaCO2 35, and HCO3 24.
Correct Answer: C
Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.
You may also like to solve these questions
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply.
- A. Use a sunscreen of SPF 30 or greater when in the sunlight.
- B. Notify the HCP immediately when developing a low-grade fever.
- C. Some dyspnea is expected and does not need immediate attention.
- D. The hands and feet may change color if exposed to cold or heat.
- E. Explain the client can be cured with continued therapy.
Correct Answer: A,B,D
Rationale: Sunscreen, fever reporting, and Raynaud’s phenomenon awareness prevent SLE flares and complications. Dyspnea requires attention, and SLE is not curable.
Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)?
- A. Fever, cough, and shortness of breath.
- B. Oral thrush, esophagitis, and vaginal candidiasis.
- C. Abdominal pain, diarrhea, and weight loss.
- D. Painless violet lesions on the face and tip of nose.
Correct Answer: A
Rationale: Fever, cough, and shortness of breath indicate Pneumocystis pneumonia, the most common AIDS opportunistic infection. Candidiasis, GI symptoms, and Kaposi’s sarcoma are less frequent.
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
- A. The client has no apparent change in the assessment data.
- B. There is increased amplitude of electrical stimulation in the muscle.
- C. The circulating acetylcholine receptor antibodies are decreased.
- D. The client shows a marked improvement of muscle strength.
Correct Answer: D
Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.