Nokea
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.
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While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis 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 because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation.
A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy.
C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy.
D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
In which clients is electroconvulsive therapy (ECT) usually contraindicated?
- A. Clients with cardiac or neurovascular diseases
- B. Clients who have not responded to drug therapy
- C. Clients who are intolerant of the side effects of antidepressant medications
- D. Clients who are extremely suicidal
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has received preoperative teaching for a vertical partial laryngectomy. The nurse determines that the teaching has been effective when the client states:
- A. I know I will need special swallowing training after my surgery.'
- B. The quality of my voice will be excellent after surgery.'
- C. I will have very little difficulty swallowing after surgery.'
- D. I may also have to have a radical neck dissection done.'
Correct Answer: C
Rationale: Special swallowing training is required for a client with a supraglottic (horizontal partial) laryngectomy, not a vertical partial laryngectomy. The quality of the client's voice will be altered, but it will be adequate for communication. The client will have minimal difficulty swallowing. A radical neck dissection may be done with a total laryngectomy, not with a partial laryngectomy.
A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?
- A. Document findings.
- B. Administer O2 therapy.
- C. Position client in high-Fowler's position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct answer is A: Document findings. This is important because the harsh hollow sound over the trachea and larynx could indicate a potential emergency or serious condition like an airway obstruction or laryngeal edema. Documenting findings helps in providing clear communication to other healthcare professionals and ensures proper follow-up care. Administering O2 therapy (B) or albuterol (D) without a clear understanding of the underlying issue could be harmful. Positioning the client in high-Fowler's position (C) may not directly address the potential emergency at hand.
Mrs. Brown asks about the difference between wide- and narrow-angle glaucoma. Which of the following responses would be most appropriate?
- A. With wide-angle glaucoma there is a minimal increase in ocular pressure.
- B. Wide-angle glaucoma is usually asymptomatic.
- C. Complications from narrow-angle glaucoma are less severe than those from wide-angle glaucoma.
- D. Narrow-angle glaucoma is usually asymptomatic.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.