Nokea
The first standard-step-in oxygen therapy that the nurse should do is which of the following?
- A. Prepare the patient for the oxygen treatment
- B. Check the chart for ordered flow rate and oxygen delivery method.
- C. Gather all the equipment and supplies.
- D. Assess patient's condition.
Correct Answer: D
Rationale: Before initiating any oxygen therapy, it is crucial for the nurse to first assess the patient's condition. This step allows the nurse to determine the patient's oxygen saturation levels, respiratory rate, lung sounds, and overall respiratory status. Understanding the patient's baseline condition helps in selecting the appropriate oxygen delivery method and flow rate that will best meet the patient's needs. Additionally, assessing the patient's condition allows the nurse to monitor the effectiveness of the oxygen therapy and make any necessary adjustments throughout the treatment process. Therefore, assessing the patient's condition is the necessary first step in providing safe and effective oxygen therapy.
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A postpartum client exhibits signs of wound infection, including erythema, warmth, and purulent drainage from a cesarean incision. Which nursing action is most appropriate?
- A. Applying a sterile dressing to the incision
- B. Irrigating the wound with saline solution
- C. Notifying the healthcare provider immediately
- D. Administering oral antibiotics as prescribed
Correct Answer: C
Rationale: When a postpartum client exhibits signs of wound infection, such as erythema, warmth, and purulent drainage from a cesarean incision, it is essential to notify the healthcare provider immediately. Wound infections can lead to serious complications if not promptly addressed. The healthcare provider will assess the infection, possibly order further diagnostic tests, and determine the appropriate course of treatment, which may include antibiotics or additional wound care measures. Applying a dressing or irrigating the wound may be part of the treatment plan prescribed by the healthcare provider, but the first step is always to seek guidance from the provider.
During the immediate post-operative phase , the PRIMARY goal of the health care team is to maintain ventilation. Which of the following situations should be observed as a result of hypoxemia?
- A. Excess carbon dioxide in the blood
- B. Increasing ammonia in the blood
- C. Decreased oxygen saturation
- D. Reduction of blood Ph
Correct Answer: C
Rationale: One of the main consequences of hypoxemia, which is low oxygen levels in the blood, is decreased oxygen saturation. Oxygen saturation refers to the percentage of hemoglobin molecules in the blood that are bound to oxygen. When there is insufficient oxygen in the blood due to hypoxemia, the oxygen saturation levels will drop. This can lead to symptoms such as shortness of breath, confusion, rapid heart rate, and ultimately can result in tissue damage if not corrected promptly. Monitoring oxygen saturation levels is crucial in the immediate post-operative phase to ensure adequate ventilation and oxygenation for the patient's recovery.
Type I IgE-mediated immediate hypersensitivity reaction is promptly managed with ____.
- A. theophylline
- B. epinephrine
- C. costicosteroid
- D. diphenhydramine
Correct Answer: B
Rationale: Type I IgE-mediated immediate hypersensitivity reactions, such as anaphylaxis, are promptly managed with epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps counteract the severe symptoms by relaxing the muscles in the airways, constricting blood vessels, and decreasing swelling. It acts quickly to reverse the potentially life-threatening effects of the allergic reaction and is crucial in managing anaphylaxis effectively. Other medications like antihistamines (e.g., diphenhydramine) and corticosteroids may be used as adjuncts, but epinephrine remains the primary treatment for immediate hypersensitivity reactions.
What is NOT important for Myra to do when listening to tape recordings?
- A. Do the listening as soon as possible after the interview.
- B. Note for the voice tone and voice inflection.
- C. Listen when she feels the motivation for a more productive time.
- D. Take notice of the pauses of the participants.
Correct Answer: C
Rationale: It is not important for Myra to listen to the tape recordings only when she feels motivated or productive. In a nurse-patient interaction relationship, listening to tape recordings promptly (Choice A) is crucial because it ensures that any important information or cues are not missed or forgotten. Additionally, noting voice tone and inflection (Choice B) and observing pauses (Choice D) are essential for understanding the nuances and emotions conveyed during the interaction, which can be crucial in effective communication. Listening based on motivation may lead to delays and hamper the timely analysis and understanding of the interactions. Hence, it is important for Myra to prioritize active and focused listening to the tape recordings, regardless of her current motivation levels.
A patient is prescribed a benzodiazepine for the management of anxiety. Which instruction should the nurse include in patient education about benzodiazepine therapy?
- A. "Take the medication with grapefruit juice for enhanced absorption."
- B. "Avoid consuming alcohol while on benzodiazepine therapy."
- C. "Take the medication on an empty stomach for better effectiveness."
- D. "Discontinue the medication abruptly if you experience side effects."
Correct Answer: B
Rationale: Consuming alcohol while on benzodiazepine therapy can increase the central nervous system depressant effects of benzodiazepines, leading to excessive sedation, respiratory depression, and even overdose. It is important for patients to avoid alcohol to prevent these potential dangerous interactions and to ensure the safe and effective use of their medication.