Nokea
The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
- A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
- B. Administer 15 mL of sterile fluid into the tube prior to suctioning
- C. Suction for no longer than 30 seconds at a time
- D. Wait 30 seconds after suctioning before attempting again
Correct Answer: A
Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.
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The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
- A. Teach about the reason for the blood tests.
- B. Schedule an appointment for a chest x-ray.
- C. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
- D. Instruct the patient to expectorate three specimens as soon as possible.
Correct Answer: C
Rationale: The correct action for the nurse to take is to teach the patient about the need to collect sputum specimens for 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. It is important to obtain these specimens on different days rather than all at once. Blood tests are not used for tuberculosis testing, so teaching about blood tests is not relevant. While a chest x-ray is important in tuberculosis diagnosis, it is not a bacteriologic test. The appearance on a chest x-ray alone is not sufficient to diagnose TB as other diseases can have similar findings.
The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
- A. The oxygen saturation is 94%.
- B. The blood pressure is 98/56 mm Hg.
- C. The patient's central IV line is disconnected.
- D. The international normalized ratio (INR) is prolonged.
Correct Answer: C
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the healthcare provider?
- A. The Mantoux test induration measured 7 mm.
- B. The chest x-ray revealed infiltrates in the lower lobes.
- C. The patient is receiving antiretroviral therapy for HIV infection.
- D. The patient has a cough producing blood-tinged mucus.
Correct Answer: C
Rationale: The most critical information to communicate to the healthcare provider in a patient diagnosed with both HIV and active TB disease is that the patient is receiving antiretroviral therapy for HIV infection. This is crucial because drug interactions can occur between antiretrovirals used to treat HIV infection and medications used to treat TB. By informing the healthcare provider about the antiretroviral therapy, potential interactions can be assessed and managed effectively to optimize patient care. The other data provided, such as the Mantoux test result, chest x-ray findings, and presence of blood-tinged mucus, are important clinical information but are expected in a patient with coexisting HIV and TB and do not directly impact potential drug interactions between antiretrovirals and TB medications.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
- A. Administer anticoagulant drug therapy.
- B. Notify the patient's healthcare provider.
- C. Prepare the patient for a spiral computed tomography (CT).
- D. Elevate the head of the bed to a semi-Fowler's position.
Correct Answer: D
Rationale: The patient presents with symptoms indicative of a pulmonary embolism (PE), such as chest pain, difficulty breathing, tachycardia, hypotension, and tachypnea. Elevating the head of the bed to a semi-Fowler's position is the priority to improve ventilation and gas exchange. This intervention should be initiated promptly to optimize oxygenation. Subsequent actions, such as notifying the healthcare provider, preparing for a spiral CT scan, and administering anticoagulant therapy, can follow after the patient's position is adjusted. The spiral CT scan is typically used to confirm the diagnosis of PE, and anticoagulant therapy is initiated upon confirmation of the diagnosis by the healthcare provider. Therefore, the immediate focus is on improving the patient's respiratory status by elevating the head of the bed.
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
- A. Start an IV so contrast media may be given
- B. Ensure that the patient has been NPO for at least 6 hours.
- C. Inform radiology that a radioactive glucose preparation is needed
- D. Instruct the patient to undress to the waist and remove any metal objects
Correct Answer: A
Rationale: For diagnosing pulmonary emboli, spiral computed tomography (CT) scans are commonly used, and contrast media may be given intravenously (IV) during the scan to enhance visualization of blood vessels. Chest x-rays are not typically diagnostic for pulmonary embolism. When preparing for a chest x-ray, the patient needs to undress and remove any metal objects. Bronchoscopy is used for examining the bronchial tree, not for assessing vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are primarily used to detect malignancies, and a radioactive glucose preparation is utilized for this purpose.