Nokea
When caring for a client with influenza, the nurse would expect to assess for which signs and symptoms of hypoxia? Select all that apply.
- A. Cough
- B. Restlessness
- C. Fever
- D. Tachypnea
- E. Use of accessory muscles to breathe
- F. Cyanosis
Correct Answer: B, D, E, F
Rationale: Hypoxia manifests as restlessness, tachypnea, use of accessory muscles, and cyanosis due to inadequate oxygen delivery to tissues.
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Which health measure is most important to emphasize when instructing the client on ways to prevent transmitting tuberculosis?
- A. Eat a nutritious diet.
- B. Get adequate sleep.
- C. Cover your nose and mouth when coughing.
- D. Wash your hands before and after meals.
Correct Answer: C
Rationale: Covering the nose and mouth when coughing prevents the spread of tuberculosis, an airborne disease, to others.
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
- A. The client requests a consultation by the speech therapist.
- B. The client has a towel placed over the mirror.
- C. The client is attempting to shave himself.
- D. The client practices neck and shoulder exercises.
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: A patient with ACTIVE TB is contagious. The bacterium, mycobacterium tuberculosis which causes TB, is so small that it can stay suspended in the air for hours to days. Therefore, the nurse will place the patient in AIRBORNE precautions. In addition, a special mask must be worn called a respirator (as referred to as an N95 mask.....a surgical mask does NOT work with this condition).
The charge nurse is making rounds. Which client should the nurse assess first?
- A. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude.
- B. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities.
- C. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL.
- D. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.
Correct Answer: C
Rationale: Blood glucose 189 mg/dL in DKA (C) indicates potential instability, requiring immediate assessment. Rudeness (A), edema (B), and stable COPD (D) are less urgent.