Nokea
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.
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The nurse provides directions to the client on the proper use of a peak flow meter. Arrange the steps for the nurse's instruction to the client on the proper use of a peak flow meter in the correct sequence.
- A. Slide the marker to zero.
- B. Take a deep breath.
- C. Put the mouthpiece of the flow meter into your mouth.
- D. Blow out as fast as you can.
- E. Empty all of the air from your lungs.
- F. Record the highest rating after the current sequence.
Correct Answer: A, B, C, D, E, F
Rationale: The correct sequence is: 1. Slide the marker to zero, 2. Take a deep breath, 3. Put the mouthpiece in your mouth, 4. Blow out as fast as you can, 5. Empty all of the air from your lungs, 6. Record the highest rating.
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
- A. Establish a means of communication.
- B. Prepare the bowel by administering enemas until clear.
- C. Teach the client to use an artificial larynx.
- D. Demonstrate the technique for suctioning a laryngectomy tube.
Correct Answer: A
Rationale: Establishing a means of communication is the highest priority preoperatively, as the client will lose the ability to speak post-laryngectomy.
The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach?
- A. Investigational regimens provide a better chance of survival for the client.
- B. Investigational treatments have not been proven to be helpful to clients.
- C. Clients will be paid to participate in an investigational program.
- D. Only clients who are dying qualify for investigational treatments.
Correct Answer: B
Rationale: Investigational treatments (B) lack proven efficacy, requiring informed consent. Better survival (A), payment (C), and terminal status (D) are incorrect.
The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client?
- A. Have you had the flu shot in the last two (2) weeks?
- B. Are there any small children in the home?
- C. Are you taking over-the-counter medicine for these symptoms?
- D. Do you have any cold sores associated with your sneezing?
Correct Answer: C
Rationale: Sneezing and nasal discharge suggest a URI; asking about OTC medications (C) assesses self-treatment and potential interactions. Flu shot timing (A) is irrelevant, children (B) are secondary, and cold sores (D) relate to herpes, not URI.
Which statement is correct regarding mycobacterium tuberculosis?
- A. This bacterium is an anaerobic type of bacteria.
- B. It is an alkali bacterium that stains bright red during an acid-fast smear test.
- C. It is known as being an aerobic type of bacteria.
- D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.
Correct Answer: C
Rationale: Mycobacterium tuberculosis is AEROBIC (it thrives in conditions that are high in oxygen), and it is an ACID-FAST bacterium, which means when it is stained during an acid-fast smear it will turn BRIGHT RED.