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A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: The correct answer is B. Intact skin behind the ears indicates that the oxygen delivery device is fitted properly and not causing skin breakdown, ensuring client safety. A (meals being eaten) is not directly related to oxygen therapy outcomes. C (client understanding) is important but doesn't directly assess client safety with oxygen therapy. D (unchanged weight) is not a specific indicator of client safety with oxygen therapy.
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A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds
- C. Productive cough
- D. Incisional discomfort
Correct Answer: B
Rationale: The correct answer is B: Absent breath sounds. This finding could indicate a pneumothorax, a serious complication post lung biopsy requiring immediate intervention. Absent breath sounds suggest air accumulation in the pleural space, causing lung collapse. Prompt action is crucial to prevent respiratory distress. Increased temperature (A) may indicate infection but not as urgent as addressing a pneumothorax. Productive cough (C) is common post-procedure. Incisional discomfort (D) is expected and can be managed with appropriate pain relief measures.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
- A. 1 L/min
- B. 2 L/min
- C. 6 L/min
- D. 10 L/min
Correct Answer: B
Rationale: The correct answer is B: 2 L/min. The rationale is that in emphysema, high oxygen flow rates can cause oxygen toxicity. The recommended maximum flow rate for patients with emphysema is typically 2 L/min to prevent oxygen toxicity. Choice A (1 L/min) may not provide sufficient oxygen, choice C (6 L/min) and choice D (10 L/min) are too high and can lead to oxygen toxicity in patients with emphysema. Therefore, choice B is the most appropriate and safe option for this client.
A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over tenderness across the cheeks and postnasal discharge. What instruction will be most helpful?
- A. Ice packs may help with the facial pain.
- B. Limit fluids to dry out your sinuses.
- C. Try warm, moist heat packs on your face.
- D. We will schedule a computed tomography scan this week.
Correct Answer: C
Rationale: The correct answer is C: Try warm, moist heat packs on your face. Warm, moist heat can help relieve facial pain and sinus pressure by promoting sinus drainage and reducing inflammation. Ice packs may not be as effective for this type of pain. Limiting fluids can worsen symptoms by drying out the sinuses. Scheduling a CT scan is not necessary at this point as the symptoms described are indicative of sinusitis, which can often be managed with conservative measures like warm compresses.
The nurse has instructed the client on how to obtain a sputum culture. Which of the statements indicates that the client understood the instruction from the nurse?
- A. I need to restrict my fluids 8 hours before obtaining the specimen.
- B. Mouth care should be avoided before collecting the sputum specimen.
- C. The best time to obtain the specimen is late at night.
- D. I just need to breathe deeply, followed by coughing up the sputum.
Correct Answer: D
Rationale: The correct answer is D because the client demonstrates understanding by acknowledging the need to breathe deeply and cough up the sputum to obtain a sputum culture. This action helps bring up the lower respiratory tract secretions for an accurate culture. Choice A is incorrect because increasing fluids actually helps in sputum production. Choice B is incorrect as mouth care should be done before to prevent contamination. Choice C is incorrect as early morning is the best time due to the accumulation of secretions overnight.
A client has returned to the coronary care unit after having a coronary angiogram. Which assessment data indicate the need for immediate action by the nurse?
- A. Diminished pedal pulse volume
- B. Heart rate 100 beats/min
- C. Blood pressure 104/60 mm Hg
- D. Capillary refill less than 3 seconds
Correct Answer: A
Rationale: The correct answer is A: Diminished pedal pulse volume. This indicates potential circulation compromise, which can lead to ischemia or impaired tissue perfusion. Immediate action is required to prevent further complications. B: Heart rate 100 beats/min is within normal range. C: Blood pressure 104/60 mm Hg is slightly low but not critically concerning. D: Capillary refill less than 3 seconds indicates good peripheral perfusion.