Nokea
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
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Which nursing observation provides the best evidence that postural drainage is effective?
- A. The client's respiratory rate is increased.
- B. The client's heart rate is much improved.
- C. The client's sputum culture is negative.
- D. The client raises a large volume of sputum.
Correct Answer: D
Rationale: Raising a large volume of sputum indicates that postural drainage is effectively clearing secretions from the airways.
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45, Paco2 54, Hco3 25, Pao2 52. Which should the nurse implement? Select all that apply.
- A. Apply oxygen via nonrebreather mask.
- B. Call the rapid response team (RRT).
- C. Elevate the head of the bed.
- D. Stay with the client.
- E. Notify the health-care provider (HCP).
Correct Answer: A,B,C,D,E
Rationale: PaO2 52 and PaCO2 54 indicate severe hypoxia; apply nonrebreather (A), call RRT (B), elevate HOB (C), stay with client (D), and notify HCP (E) are all critical.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.
Which referral is most appropriate for a client diagnosed with end-stage COPD?
- A. The Asthma Foundation of America.
- B. The American Cancer Society.
- C. The American Lung Association.
- D. The American Heart Association.
Correct Answer: C
Rationale: The American Lung Association (C) supports COPD patients with resources. Asthma Foundation (A), Cancer Society (B), and Heart Association (D) are less relevant.