Nokea
What nursing action is most appropriate if Mr. Puff is lying flat in bed with shallow respirations and cyanosis?
- A. Change his nasal cannula to a Venturi mask
- B. Offer him water to increase his fluid intake
- C. Offer to walk him in the hall to increase his mobility
- D. Sit him up in bed with arms resting on pillows on the overbed table
Correct Answer: D
Rationale: Upright positioning enhances diaphragmatic movement and oxygenation.
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Mandy is a 17-year-old adolescent girl. On physical examination you note partial erosion of her tooth enamel and callus formation on the posterior aspect of the knuckles of her hand. This is indicative of
- A. A connective tissue disorder; she should be referred to dermatology.
- B. Self-induced vomiting; she likely has bulimia nervosa.
- C. Self-mutilation; this correlates with anxiety.
- D. A genetic disorder; her siblings should also be tested.
Correct Answer: B
Rationale: Erosion of tooth enamel and calluses on knuckles are common signs of self-induced vomiting seen in bulimia nervosa.
The patient asks you what the clip on his finger is for. The best response is
- A. This is a cardiac monitor that alerts us to any arrhythmia that you might experience during the night.
- B. This measures your temperature.
- C. This is pulse oximetry and is used to give us an idea of how much oxygen is in your blood.
- D. This tells us the number of red blood cells you have. These cells provide oxygen throughout your body.
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation in the blood.
A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen via face mask. Given the client's symptoms and ABG results showing respiratory alkalosis and hypoxemia, the priority is to improve oxygenation. Administering oxygen via face mask will help increase the oxygenation levels and alleviate the hypoxemia. Mechanical ventilation (A) is not indicated as the client is able to maintain their own ventilation. Administering a sedative (C) is not appropriate without addressing the underlying respiratory issue. Assessing for pulmonary embolism (D) may be important but not the immediate priority in this case.
Which action occurs primarily during the evaluation phase of the nursing process?
- A. Data collection.
- B. Decision-making and judgment.
- C. Priority-setting and expected outcomes.
- D. Reassessment and audit.
Correct Answer: B
Rationale: Evaluation involves assessing whether goals were met and making judgments about care effectiveness.
Which of the following cancer patients could less ergenically be placed together as roommates?
- A. A patient with a neutrophil count of 1000/mm³.
- B. A patient who underwent debulking of a tumor to relieve pressure.
- C. A patient receiving high-dose chemotherapy after a bone marrow harvest.
- D. A patient who is post-op laminectomy for spinal cord compression.
Correct Answer: B
Rationale: Patients undergoing debulking surgery are generally less immunocompromised compared to those receiving high-dose chemotherapy or with severely low neutrophil counts.