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The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
- A. Breath sounds can be heard bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88 BPM
- D. Client is unable to speak
Correct Answer: C
Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.
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A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
Correct Answer: B
Rationale: Check the client's gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
The nurse provides a collection container to the client for collecting a sputum specimen for culture and sensitivity. Which additional interventions should the nurse implement? Select all that apply.
- A. Tell the client to spit into the container 2 to 3 times during the day.
- B. Wear gloves and protective eyewear when handling the specimen.
- C. After collection, place the sealed container in a clean plastic bag.
- D. Place a biohazard alert symbol on the bag containing the specimen container.
- E. Send the specimen to the laboratory within 30 minutes of collection.
Correct Answer: C,D,E
Rationale: C: A clean bag prevents external contamination. D: A biohazard symbol indicates infectious material. E: Prompt delivery ensures accurate results. A: Single morning collection is preferred. B: Eyewear is unnecessary.
A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: Potassium. If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.