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When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing.
- B. Ask the RN to assess the vital signs.
- C. Measure the pulse oximetry.
- D. Continue to monitor respirations.
Correct Answer: C
Rationale: Pulse oximetry provides critical data on oxygenation.
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What are life-threatening complications of shock?
- A. Catheter infection
- B. Pulmonary edema
- C. Kidney failure
- D. Stasis ulcers
Correct Answer: C
Rationale: Kidney failure is a severe complication of shock due to prolonged hypoperfusion and ischemi
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
What statement indicates Mr. Singer understands his condition after viewing a filmstrip on rehabilitation?
- A. ‘I will be able to continue my swimming as usual.’
- B. ‘I will regain some degree of my sense of smell and taste.’
- C. ‘I will not be able to bowl any more.’
- D. ‘I will have to give up my tub bath.’
Correct Answer: B
Rationale: Partial recovery of senses is possible after laryngectomy.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
Which type of therapy helps clients alter irrational thinking and replace negative self-statements with positive ones?
- A. Desensitization therapy
- B. Behavioral therapy
- C. Cognitive therapy
- D. Psychobiologic therapy
Correct Answer: C
Rationale: Cognitive therapy focuses on identifying and challenging irrational beliefs, helping clients develop healthier thought patterns.