Nokea
The nurse is planning the activities for the client diagnosed with asbestosis. Which activity should the nurse schedule at 0900 if breakfast is served at 0800?
- A. Assist with the client's bath and linen change.
- B. Administer an inhalation bronchodilator treatment.
- C. Provide the client with a one (1)-hour rest period.
- D. Have respiratory therapy perform chest physiotherapy.
Correct Answer: B
Rationale: Bronchodilator treatment (B) at 0900 optimizes lung function early in the day for asbestosis patients, who have restrictive lung disease. Bathing (A) is less urgent. A rest period (C) may be needed later, not immediately post-breakfast. Chest physiotherapy (D) is typically scheduled later to avoid postprandial discomfort.
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The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?
- A. Gather the needed supplies for the procedure.
- B. Obtain a signed informed consent form.
- C. Assist the client into a side-lying position.
- D. Discuss the procedure with the client.
Correct Answer: B
Rationale: Informed consent (B) is required before invasive procedures, a priority. Gathering supplies (A), positioning (C), and discussion (D) follow.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy?
- A. I must avoid hair spray and powders.
- B. I should take a shower instead of a tub bath.
- C. I will need to cleanse around the stoma daily.
- D. I can use an electric larynx to speak.
Correct Answer: D
Rationale: Using an electric larynx (D) is related to speech, not tracheostomy care, indicating a misunderstanding of tracheostomy management. Avoiding hair spray/powders (A), showering (B), and daily stoma cleaning (C) are correct tracheostomy care practices.
Which pulse oximetry reading indicates to the nurse that the client has normal tissue oxygenation?
- A. 80 to 90 mm Hg
- B. 95 to 100 mm Hg
- C. 80% to 85%
- D. 95% to 100%
Correct Answer: D
Rationale: A pulse oximetry reading of 95% to 100% indicates normal tissue oxygenation, reflecting adequate oxygen saturation.
The nursing staff on an oncology unit is interviewing applicants for the unit manager position. Which type of organizational structure does this represent?
- A. Centralized decision making.
- B. Decentralized decision making.
- C. Shared governance.
- D. Pyramid with filtered-down decisions.
Correct Answer: C
Rationale: Staff interviewing for a manager (C) reflects shared governance, empowering nurses in decisions. Centralized (A), decentralized (B), and pyramid (D) involve top-down structures.