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When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings.
A: Encouraging fluid intake is important but not the first priority.
C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress.
D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.
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You have been pulled to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Calcium
Correct Answer: B
Rationale: Prominent U waves on an ECG strip are typically associated with hypokalemia (low potassium levels). Checking potassium levels is critical to address potential cardiac complications.
The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)?
- A. Anxiety
- B. Fear of pain
- C. The dying process
- D. Anger toward the nurse.
Correct Answer: A
Rationale: The nurse can address anxiety, fear of pain, and the dying process through education, medication, and emotional support, while anger toward the nurse might require conflict resolution strategies.
What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.
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.