Nokea
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?
- A. The client's pulse oximeter reading is 92%.
- B. The client's arterial blood gas level is 74.
- C. The client has SOB when walking to the bathroom.
- D. Rusty colored sputum.
Correct Answer: D
Rationale: Rusty sputum (D) suggests hemoptysis or infection, a critical finding in end-stage COPD. SpO2 92% (A), PaO2 74 (B), and SOB (C) are expected but less urgent.
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Which nursing action is essential before suctioning the client with a tracheostomy tube?
- A. Preoxygenating the client
- B. Maintaining the head in a flexed position
- C. Cleaning around the stoma
- D. Removing the inner cannula
Correct Answer: A
Rationale: Preoxygenating the client prevents hypoxia during suctioning, which can temporarily reduce oxygen intake.
Which explanation to the client by the nurse regarding the use of antibiotics is best?
- A. Antibiotics are ineffective in treating viral infections.
- B. Antibiotics are ineffective after cold symptoms develop.
- C. Antibiotics only prevent the spread of colds to others.
- D. Antibiotics are used only for immunosuppressed individuals.
Correct Answer: A
Rationale: Head colds are typically caused by viruses, and antibiotics are effective against bacterial infections, not viral ones.
You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
- A. Easily fatigued with physical activity
- B. Reduced peak flow meter reading
- C. Chest retractions
- D. Cyanosis
- E. Wheezing with activity
- F. Nighttime coughing
- G. No relief with short-acting bronchodilator inhaler
Correct Answer: A,B,E,F
Rationale: Early warning signs include fatigue, reduced peak flow, wheezing with activity, and nighttime coughing. Chest retractions, cyanosis, and no relief from a bronchodilator indicate a more severe attack.
An adult is to have a tracheostomy performed. What is the nursing priority?
- A. Shave the neck
- B. Establish a means of communication
- C. Insert a Foley catheter
- D. Start an IV
Correct Answer: B
Rationale: Establishing a means of communication is the priority, as the client will lose the ability to speak post-tracheostomy.
What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.