Nokea
What goal assumes the highest priority for Ms. Weeze with an acute asthmatic attack?
- A. Preventing future attacks
- B. Maintaining quiet, restful environment
- C. Observing for signs of drug toxicity
- D. Relieving bronchial spasm
Correct Answer: D
Rationale: Relieving bronchospasm is critical to restore adequate airflow.
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What complication can result from tracheal suctioning?
- A. Acute hypoxemia
- B. Gastric dilatation
- C. Hypervolemic shock
- D. Epiglottitis
Correct Answer: A
Rationale: Suctioning temporarily reduces oxygen levels, necessitating careful monitoring.
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.
A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
- A. Pertussis
- B. Mycoplasma pneumonia
- C. Tuberculosis
- D. Respiratory syncytial virus
Correct Answer: C
Rationale: The correct answer is C: Tuberculosis. Healthcare workers should wear an N95 respirator mask when caring for clients with airborne infectious diseases like tuberculosis. The N95 mask is designed to filter out at least 95% of airborne particles, including those that may carry the tuberculosis bacteria. This level of protection is necessary to prevent the healthcare worker from inhaling the infectious agent.
Pertussis (A), Mycoplasma pneumonia (B), and Respiratory syncytial virus (D) are not typically transmitted through the air and therefore do not require the use of an N95 respirator mask for standard care. These diseases are usually spread through respiratory droplets or direct contact, so standard precautions such as wearing a surgical mask and gloves are sufficient.
Which tubes drain gastric contents (select all that apply)?
- A. T-tube
- B. Hemovac
- C. Nasogastric tube
- D. Indwelling catheter
Correct Answer: D
Rationale: Nasogastric and gastrointestinal tubes drain gastric contents effectively.
Which physical assessment finding should be reported to the physician?
- A. Pearly gray or pink tympanic membrane
- B. Dense, whitish ring at the circumference of the tympanum
- C. Bulging red or blue tympanic membrane
- D. A cone of light at the innermost part of the tympanum
Correct Answer: C
Rationale: A bulging red or blue tympanic membrane indicates acute otitis media or other serious conditions requiring medical intervention.