Nokea
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?
- A. Check the ventilator settings every shift.
- B. Suction the endotracheal tube as needed.
- C. Monitor the client’s oxygen saturation.
- D. Ensure the endotracheal tube is secure.
Correct Answer: D
Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.
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A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following?
- A. Fatigue, pallor, and exertional dyspnea.
- B. Nausea, vomiting, and diarrhea.
- C. Vertigo, dizziness, and shortness of breath.
- D. Malaise, flushing, and tachycardia.
Correct Answer: A
Rationale: these 'constitutional symptoms' are characteristic of most types of anemia and are predominantly the result of tissue hypoxia secondary to inadequate red blood cells
The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should
- A. place the patient on bedrest and elevate the foot of the bed six inches.
- B. ask the patient to remain in bed and place a pillow under the knee to elevate her left leg.
- C. ambulate the patient as directed to prevent complications of bedrest.
- D. obtain thigh-high compression or elastic stockings and continue ambulating the patient.
Correct Answer: A
Rationale: promotes venous return and decreases venous pressure relieving pain and edema
A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation