Nokea
What information should you immediately report to the physician?
- A. The parent is unsure about the child's tetanus immunization status
- B. The child is upset and pulls out the IV
- C. The parent declines the IV conscious sedation
- D. The parent wants information about the IV conscious sedation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
When the nurse takes a surgical consent form to an Asian woman for a signature after the surgeon has provided the information about the recommended surgery, the patient refuses to sign the consent form. What is the best response by the nurse?
- A. Didn’t you understand what the doctor told you about the surgery?
- B. Are there others with whom you want to talk before making this decision?
- C. Why won’t you sign this form? Do you want to do what the doctor recommended?
- D. I’ll have to call the surgeon and have your surgery cancelled until you can make a decision.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How is the initial information given to the PACU nurses about the surgical patient?
- A. A copy of the written operative report
- B. A verbal report from the circulating nurse
- C. A verbal report from the anesthesia care provider (ACP)
- D. An explanation of the surgical procedure from the surgeon
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications.
A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease.
B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action.
C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.