Nokea
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
- A. Apply petroleum jelly around the inside of the nares
- B. Remove the nasal cannula during mealtimes
- C. Check the position of the cannula often
- D. Report any nasal stuffiness, nausea, or fatigue
- E. Post 'no smoking' signs in a prominent location
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.
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A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
- A. Obtain culture specimens before initiating antimicrobials
- B. Restrict the client's oral fluid intake
- C. Encourage the client to limit activity & rest
- D. Allow the client to shiver to dispel excess heat
- E. Assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale: Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
- A. Fat
- B. Protein
- C. Glycogen
- D. Carbohydrates
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are the primary source of energy for the body, especially during high-intensity activities like sports. When consumed, carbohydrates are broken down into glucose, which is used for immediate energy or stored as glycogen in muscles and the liver for later use. Fat is a long-term energy reserve but is not as readily accessible as carbohydrates for quick energy. Protein is primarily used for building and repairing tissues, not as a main energy source. Glycogen is a stored form of carbohydrates in the body, not the primary energy reserve.
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
- E. Rosenbaum test
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.