Nokea
The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?
- A. Client with emphysema expecting discharge
- B. Bronchitis client receiving IV antibiotics
- C. Bronchitis client with edema and neck vein distention
- D. COPD client with PO2 of 85
Correct Answer: C
Rationale: Edema and neck vein distention in a bronchitis client suggest heart failure, a critical condition requiring immediate assessment. The other clients are stable or less urgent.
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The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's stomach placement?
- A. Aspiration of tan-colored mucus
- B. Green aspirate with a pH of 3
- C. A swish auscultated with the injection of air
- D. Bubbling in a cup of NS when the end of the tube is placed in the cup
Correct Answer: B
Rationale: A green aspirate with a pH of 3 confirms gastric placement, as stomach contents are acidic and often green due to bile, providing the most reliable indicator.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin
- B. Wash the skin with water and pat dry
- C. Cover the area with a petroleum gauze
- D. Apply an occlusive dressing to the site
Correct Answer: B
Rationale: Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.
The first exercise that should be performed by the client who had a mastectomy 1 day earlier is:
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: Squeezing a ball is a gentle initial exercise to restore arm mobility.