Nokea
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45, Paco2 54, Hco3 25, Pao2 52. Which should the nurse implement? Select all that apply.
- A. Apply oxygen via nonrebreather mask.
- B. Call the rapid response team (RRT).
- C. Elevate the head of the bed.
- D. Stay with the client.
- E. Notify the health-care provider (HCP).
Correct Answer: A,B,C,D,E
Rationale: PaO2 52 and PaCO2 54 indicate severe hypoxia; apply nonrebreather (A), call RRT (B), elevate HOB (C), stay with client (D), and notify HCP (E) are all critical.
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Which assessment technique is essential before allowing a client food or fluids after a bronchoscopy?
- A. Touch the arch of the palate with a tongue blade.
- B. Listen to the abdomen for active bowel sounds.
- C. Inspect the oral mucous membranes for integrity.
- D. Palpate the throat while the client swallows.
Correct Answer: D
Rationale: Palpating the throat while the client swallows confirms the gag reflex has returned, ensuring safe oral intake post-bronchoscopy.
Which statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?
- A. I should wipe the container with an alcohol swab.
- B. I must not touch the inside of the container.
- C. I cannot put the lid on the container until the container is fairly full.
Correct Answer: B
Rationale: Not touching the inside of the container prevents contamination, ensuring an accurate sputum sample.
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.
If a client is allergic to penicillin, the nurse should anticipate a hypersensitivity response to which other group of antibiotics?
- A. Aminoglycosides such as kanamycin (Kantrex)
- B. Tetracyclines such as doxycycline (Vibramycin)
- C. Cephalosporins such as ceftriaxone (Rocephin)
- D. Fluoroquinolones such as ciprofloxacin (Cipro)
Correct Answer: C
Rationale: Cephalosporins have a similar beta-lactam structure to penicillin, increasing the risk of cross-reactivity in penicillin-allergic clients.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.