Nokea
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
- A. Ensure oral suction is available.
- B. Provide frequent mouth care.
- C. Keep the room at a comfortable temperature.
- D. Maintain the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
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Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
- A. chronic bronchitis
- B. anxiety disorder
- C. exercise-induced bronchospasm
- D. impaired gas exchange
- E. cardiovascular disease
- F. respiratory infection
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Using salt, herbs, and spices will improve the flavor of foods.
- B. Restrict alcoholic beverages to no more than 1-2 per week.
- C. Eat a protein snack 30 minutes before any exercise workout.
- D. Get an influenza vaccine every year as soon as available.
Correct Answer: D
Rationale: Getting an influenza vaccine every year is a crucial aspect of diabetes self-management, as people with diabetes are at increased risk of complications from influenza.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a bland diet and avoid spicy foods.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a soft diet with increased intake of milk and milk products.
- D. Eat a high fiber diet and increase fluid intake.
Correct Answer: D
Rationale: Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis, promoting regular bowel movements and preventing constipation.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Assess the pin sites for signs of infection.
- B. Administer pain medication at designated intervals around the clock.
- C. Assess the pulses proximal to the fracture site.
- D. Remove traction every shift and provide skin care.
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
- A. Decrease in heart rate from 112 to 105 beats per minute.
- B. Client able to speak in full sentences without pausing.
- C. Clear lung sounds.
- D. Reduction in respiratory rate to 16 breaths per minute.
- E. Client reports breathing is eased.
- F. Blood pressure within normal limits.
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.