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The client with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant?
- A. Discuss weight loss strategies such as diet and exercise with the client.
- B. Teach client how to apply the BiPAP machine before sleeping.
- C. Remind client to sleep on his side instead of his back.
- D. Administer modafinil (Provigil) to promote daytime wakefulness.
Correct Answer: C
Rationale: The correct answer is C. Reminding the client to sleep on their side is a simple intervention suitable for a nursing assistant. Discussing weight loss strategies (A) and teaching BiPAP machine use (B) require more specialized knowledge. Administering medication (D) is outside the scope of practice for a nursing assistant.
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In which organ is carbonic anhydrase crucial for maintaining acid-base balance?
- A. Liver
- B. Kidneys
- C. Heart
- D. Pancreas
Correct Answer: B
Rationale: Carbonic anhydrase is crucial for acid-base balance by catalyzing the interconversion of carbon dioxide and bicarbonate ions in the blood. The kidneys regulate blood pH by reabsorbing bicarbonate and excreting hydrogen ions. Therefore, carbonic anhydrase in the kidneys plays a vital role in maintaining acid-base balance. The liver is not directly involved in this process but helps in detoxification and metabolism. The heart and pancreas do not have a primary role in acid-base balance regulation. Thus, the correct answer is B: Kidneys.
The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds that the mask fits snugly the skin under the mask and straps is intact and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?
- A. Assess the client's oxygen saturation.
- B. Document these findings in the chart.
- C. Immediately increase the flow rate.
- D. Turn the flow rate down to 2 L/min.
Correct Answer: C
Rationale: The correct answer is C: Immediately increase the flow rate. A flow rate of 3 L/min is inadequate to deliver 50% O2 through a mask. Increasing the flow rate will ensure the client receives the prescribed oxygen concentration.
Incorrect choices:
A: Assess the client's oxygen saturation - This is not the priority as the oxygen delivery is suboptimal.
B: Document these findings in the chart - Documentation is important but addressing the oxygen delivery issue is more critical.
D: Turn the flow rate down to 2 L/min - This would further reduce the oxygen concentration, which is not appropriate in this case.
An older adult is brought to the emergency department by a family member who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best?
- A. Chest x-rays are always ordered when we suspect pneumonia.
- B. Older people often have vague symptoms, so an x-ray is essential.
- C. The x-ray can be done and read before laboratory work is reported.
- D. We are testing for any possible source of infection in the client.
Correct Answer: B
Rationale: The correct answer is B because older adults often present with atypical or vague symptoms when they have an underlying infection, including pneumonia. It is crucial to assess for pneumonia in older adults promptly because they may not exhibit classic signs like fever. An x-ray is essential to confirm or rule out pneumonia as it allows for visualization of lung abnormalities.
Choice A is incorrect because not all older adults with vague symptoms automatically have pneumonia, and ordering a chest x-ray is based on clinical judgment. Choice C is incorrect as the timing of the x-ray in relation to laboratory work is not the primary reason for ordering it. Choice D is incorrect because the x-ray is specifically to assess for pneumonia, not for general infection sources.
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:
- A. 1 minute
- B. 5 seconds
- C. 10 seconds
- D. 30 second
Correct Answer: C
Rationale: The correct answer is C: 10 seconds. Suctioning time for a tracheostomy tube should be limited to 10 seconds to prevent hypoxia and tissue damage. Prolonged suctioning can lead to decreased oxygenation and potential trauma to the airway. Choice A (1 minute) is too long and can cause harm. Choice B (5 seconds) is too short to effectively clear secretions. Choice D (30 seconds) exceeds the recommended time limit and can lead to complications. Therefore, limiting suctioning time to 10 seconds is the safest and most effective approach.
The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused,
and agitated. The patient’s temperature is 100° F, and his pulse, blood pressure, and
respirations are elevated since the last assessment 6 hours ago. What action should the nurse
take first?
- A. Auscultate the patient's lungs.
- B. Assess the patient's oxygen saturation.
- C. Administer the mild sedative as ordered.
- D. Administer an ordered analgesic for discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's oxygen saturation first. In a patient with bacterial pneumonia showing signs of restlessness, confusion, and agitation along with elevated vital signs, the priority is to assess oxygen saturation to rule out hypoxemia. Hypoxemia can lead to cognitive changes and increased agitation in older adults. Administering a sedative (choice C) or an analgesic (choice D) without addressing the underlying hypoxemia can worsen the patient's condition. Auscultating the lungs (choice A) is important but should come after assessing oxygen saturation to prioritize immediate interventions.