Nokea
What is the most appropriate intervention for a client with an obstructed airway?
- A. Administer oxygen
- B. Monitor respiratory rate
- C. Apply a cold compress
- D. Administer corticosteroids
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.
You may also like to solve these questions
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
- A. I know that my name is John. I couldn't tell you where I am. I think this year is 2009, though.
- B. I know that my name is John, but to tell you the truth, I get kind of confused about the date.
- C. I know that my name is John; I guess I'm at the hospital in Victoria. No, I don't know the date.
- D. I know that my name is John. I am at the hospital in Victoria. I couldn't tell you what date it is, but I know that it is February of a new year"”2009.
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains.
Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.
What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
- A. Administer oxygen
- B. Administer antibiotics
- C. Monitor blood glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
Which choice is *not* allowed when planning care for a client undergoing diagnostic genetic counseling?
- A. Terminating the pregnancy
- B. Preparing for the birth of a child with special needs
- C. Accessing support services before birth
- D. Completing the grieving process before birth
Correct Answer: D
Rationale: The correct answer is D because completing the grieving process before birth is not appropriate when planning care for a client undergoing genetic counseling. This is because genetic counseling aims to provide information and support to help clients make informed decisions about their pregnancy or future child's health. Grieving before birth implies assuming a negative outcome before all information is gathered, which can be premature and may not align with the purpose of genetic counseling. Choices A, B, and C are allowed as they involve valid actions such as decision-making, preparation, and accessing support services, all of which are important aspects of genetic counseling.
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
- A. Perform a neurological assessment
- B. Initiate a stroke protocol
- C. Position the client on their side
- D. Start a CT scan
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
Which disease is least likely to be associated with increased potential for bleeding?
- A. metastatic liver cancer
- B. gram-negative septicemia
- C. pernicious anemia
- D. iron-deficiency anemia
Correct Answer: C
Rationale: The correct answer is C: pernicious anemia. Pernicious anemia is caused by vitamin B12 deficiency, leading to impaired red blood cell production but does not directly affect clotting factors. Metastatic liver cancer (A) can cause liver dysfunction and decreased production of clotting factors, increasing bleeding risk. Gram-negative septicemia (B) can lead to disseminated intravascular coagulation and excessive bleeding. Iron-deficiency anemia (D) can result in microcytic red blood cells and decreased oxygen delivery but does not directly increase bleeding potential.