Nokea
What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?
- A. Administer humidified oxygen, as ordered
- B. Obtain an order for aspirin
- C. Auscultate the posterior basal segments for rales and rhonchi
- D. Explain the diagnosis to the patient
Correct Answer: A
Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.
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A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Never strip the tubing to maintain patency.
- B. Secure tubing junctions with tape to prevent accidental disconnections.
- C. Set wall suction at the level recommended by the device manufacturer.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct Answer: D
Rationale: The correct answer is D: Keep padded clamps at the bedside for use if the drainage system is interrupted. This is essential because if the drainage system is interrupted, the nurse needs to immediately clamp the tube to prevent air from entering the pleural space. Clamping the tube can prevent a potentially life-threatening situation.
A: Never strip the tubing to maintain patency - Stripping the tubing can lead to increased negative pressure, which can be harmful.
B: Secure tubing junctions with tape to prevent accidental disconnections - While securing tubing is important, clamping the tube in case of interruption is more critical.
C: Set wall suction at the level recommended by the device manufacturer - This is important for proper functioning but not as crucial as having clamps ready for emergencies.
For Mr. Jones’ persistent productive cough, what nursing action would be most appropriate?
- A. Increase intake of warm liquids
- B. Administer narcotic cough medication
- C. Monitor the amount of sputum produced each day
- D. Place the patient on strict bed rest
Correct Answer: A
Rationale: Warm liquids soothe the throat and thin mucus, facilitating expectoration.
Which of the following would indicate that Mrs. Filbert understands what you have taught her about her condition?
- A. She delays asking for medication so that she will not become addicted
- B. She asks for medication upon the first indication of an attack
- C. She permits the nurse to perform all of her morning care
- D. She asks her family to assist her at mealtime
Correct Answer: B
Rationale: Promptly seeking medication at the onset of symptoms reflects understanding of how to manage acute attacks effectively.
Identify what short-term evaluation technique is appropriate to assess whether the patient has met the following learning goals.
- A. Demonstration
- B. Verbalization
- C. Selection
- D. Observation
Correct Answer: B
Rationale: Each learning goal requires a different evaluation technique: Demonstration for subcutaneous insulin injection, Verbalization for identifying side effects of Coumadin, Selection for choosing potassium-rich foods, Observation for verbalizing no shortness of breath, and Verbalization for stating readiness to change a dressing. The correct technique depends on the specific goal.
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.