Nokea
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
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Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
- A. Teach the patient to avoid using over-the-counter expectorants.
- B. Assist the patient with chest physiotherapy and postural drainage.
- C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
- D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.
Correct Answer: D
Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan.
Which information obtained by the nurse is a priority to communicate to the health care provider
before the CT?
- A. Allergy to shellfish
- B. Apical pulse of 104
- C. Respiratory rate of 30
- D. Oxygen saturation of 90%
Correct Answer: A
Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the
CT scan without contrast or be premedicated before injection of the contrast media. The
increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment
or intervention but do not indicate a need to modify the CT procedure.
The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
- A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
- B. Administer 15 mL of sterile fluid into the tube prior to suctioning
- C. Suction for no longer than 30 seconds at a time
- D. Wait 30 seconds after suctioning before attempting again
Correct Answer: A
Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
- A. Notify the healthcare provider
- B. Document the response to exercise
- C. Administer the PRN supplemental O2
- D. Encourage the patient to pace activity
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.