Nokea
What should the nurse instruct Mr. Ross to withhold food and fluid for several hours until after fiberoptic bronchoscopy?
- A. Sputum returns to normal color and consistency
- B. Speech returns to the normal pattern
- C. Vital signs become stable
- D. Cough reflex is present
Correct Answer: D
Rationale: A functioning cough reflex prevents aspiration.
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Complications of overeating include which of the following?
- A. Hyperlipidemia
- B. Type I diabetes
- C. Sleep disturbances
- D. Rheumatoid arthritis
Correct Answer: A
Rationale: Overeating can lead to elevated cholesterol levels, contributing to hyperlipidemia and cardiovascular risks.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
- A. Determining if the UAP knew how to take blood pressure
- B. Double-checking the UAP by taking another blood pressure
- C. Providing more appropriate supervision of the UAP
- D. Taking the blood pressure instead of delegating the task
Correct Answer: C
Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier.
A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight.
B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision.
D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.
What statement by Mr. Ross indicates postural drainage has been effective?
- A. ‘I have been able to eat a little better during the past week.’
- B. ‘I have not gained any during the past week.’
- C. ‘I have not been able to sleep very well at night.’
- D. ‘I have been bringing up lots of sputum when I cough.’
Correct Answer: D
Rationale: Effective postural drainage clears secretions, evidenced by productive coughing.
Joan asks you why she is being administered so many arterial blood gas tests. You respond by saying
- A. This test determines if your liver and kidneys are functioning properly.
- B. This test determines if you have sufficient WBC to fight infection.
- C. This test determines if you are hyperglycemic, which is a side effect of your medication.
- D. This test determines how well your tissues are oxygenated.
Correct Answer: D
Rationale: Arterial blood gas tests measure oxygenation and acid-base balance in the blood.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct Answer: C
Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows:
1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital.
2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM).
3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases.
4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM).
In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.