Nokea
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm re-set button on the ventilator
Correct Answer: B
Rationale: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
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The nurse is preparing for a dressing change using surgical aseptic technique. Which action by the nurse is correct when setting up the sterile field?
- A. Dons sterile gloves before opening the package that contains the sterile drape.
- B. Uses alcohol to cleanse a bottle of irrigating solution before placing it on the sterile drape.
- C. Holds an opened sterile package 6 inches above the field to drop the item into the sterile field.
- D. Leaves the sterile field unattended to obtain the correct size of sterile gloves.
Correct Answer: C
Rationale: C: Dropping items from 6 inches above the sterile field maintains sterility by avoiding contact with non-sterile surfaces. A: Sterile gloves are donned after opening the drape. B: Non-sterile bottles cannot be placed on the sterile field. D: Leaving the field unattended risks contamination.
A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action?
- A. Wears a mask, gown, and gloves when taking the client's vital signs
- B. Wears a gown and gloves when changing the client's incontinent briefs
- C. Wears gloves when providing urinary catheter and perineal care
- D. Wears a gown and gloves when asking the client about snack food options
Correct Answer: B
Rationale: B: Gown and gloves are required for contact precautions during incontinent brief changes due to fecal transmission risk. A: Masks are unnecessary as hepatitis A is not airborne. C: Gloves alone are insufficient; a gown is needed. D: PPE is not required for non-contact interactions.
The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?
- A. "If I open the door you will need to always wear a mask."
- B. "The door must be kept closed, but I can open the curtains."
- C. "Don't worry; I can leave the door open if it's bothering you."
- D. "I'm sorry, but I can only leave the door partially open."
Correct Answer: B
Rationale: B: Keeping the door closed contains airborne pathogens; opening curtains reduces isolation feelings. A, C, D: Open or partially open doors risk pathogen spread.