Nokea
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct Answer: C
Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.
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When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?
- A. Stridor
- B. Nausea
- C. Headache
- D. Pruritus
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Chest X-ray
- B. Arterial blood gases (ABGs)
- C. Echocardiogram
- D. Electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is C: Echocardiogram. An echocardiogram should be performed first to assess ventricular function and evaluate the cause of shortness of breath and crackles in a client with heart failure. An echocardiogram provides valuable information about the heart's structure and function, helping to identify potential issues related to heart failure. Chest X-ray (Choice A) may be done to assess for changes in heart size or fluid in the lungs but does not directly assess heart function. Arterial blood gases (Choice B) may provide information about oxygenation but do not directly evaluate heart function. An electrocardiogram (Choice D) assesses the heart's electrical activity but does not provide detailed information about ventricular function, which is crucial in heart failure management.
A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Apical pulse of 58 beats per minute
- C. Presence of a new murmur
- D. Blood pressure of 100/60 mmHg
Correct Answer: C
Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.
A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which laboratory value should the nurse monitor closely?
- A. International Normalized Ratio (INR)
- B. Serum glucose level
- C. White blood cell count
- D. Prothrombin time (PT)
Correct Answer: A
Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client with atrial fibrillation to assess the effectiveness and safety of anticoagulation therapy with warfarin. Monitoring the INR helps to ensure that the client is within the therapeutic range to prevent complications such as thrombosis or bleeding. Choices B, C, and D are less relevant in this scenario. While serum glucose levels are important in assessing metabolic status, and white blood cell count and prothrombin time are important indicators for other conditions, they are not the primary focus when a client with atrial fibrillation presents with confusion.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Mucous plugging of the tracheostomy tube
- D. Yellowing of the skin around the tracheostomy site
Correct Answer: C
Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.