Nokea
When staging a pressure ulcer, you correctly recognize a stage II ulcer as
- A. Redness, with no break in the skin.
- B. Shallow ulcer with red base.
- C. Dermis involvement with eschar.
- D. Bone visible with no drainage.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What can be a cause of hyperkalemia?
- A. Severe burns
- B. Renal stones
- C. Overuse of salt
- D. Underuse of potassium supplements
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
- A. The client rates pain as 5/10 at the site of the procedure.
- B. A small amount of drainage is noted from the site.
- C. Pulse oximetry reads 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential tension pneumothorax, a life-threatening emergency requiring immediate intervention. Tracheal deviation occurs when there is a significant shift in the mediastinum due to increased pressure in the pleural space. This can compromise respiratory function and lead to respiratory failure. Options A, B, and C are not as urgent as tracheal deviation. Pain at 5/10 is expected post-thoracentesis, a small amount of drainage is common, and a pulse oximetry reading of 93% on low oxygen is concerning but not immediately life-threatening.
When teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition, what information should be included? (Select all that apply)
- A. Avoid drinking fluids just before and during meals.
- B. Rest before meals if experiencing dyspnea.
- C. Have about six small meals a day.
- D. Eat high-fiber foods to promote gastric emptying.
Correct Answer: D
Rationale: The correct answer is D: Eat high-fiber foods to promote gastric emptying. In COPD, patients may experience slow gastric emptying due to decreased lung function. High-fiber foods can help with digestion and prevent constipation.
A: Avoid drinking fluids just before and during meals - Incorrect. Hydration is important for COPD patients, but timing of fluid intake is not directly related to nutrition in this context.
B: Rest before meals if experiencing dyspnea - Incorrect. While resting before meals can help with dyspnea, it is not directly related to nutrition education.
C: Have about six small meals a day - Incorrect. While small frequent meals may be beneficial for some COPD patients, this is not a universal recommendation for all individuals with COPD in terms of nutrition.
What is your evaluation of the nursing action regarding continuous bubbling in the water-seal chamber?
- A. Incorrect, chest tubes should never be clamped because of the risk of tension pneumothorax
- B. Correct, clamping the chest tubes demonstrated that the system was intact; the leak was in the patient
- C. Partially correct, since clamping the chest tubes corrected the pattern, the nurse should have left them clamped until the physician checked the patient
- D. Partially correct, the nurse should have increased the external suction while waiting for the physician to come
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply)
- A. I held the client's morning bronchodilator medication.
- B. The client is ready to go down to radiology for this examination.
- C. Physical therapy states the client can run on a treadmill.
- D. I advised the client not to smoke for 6 hours prior to the test.
Correct Answer: B
Rationale: The correct answer is B because it communicates important information to the respiratory therapist regarding the client's readiness for the PFTs. Going down to radiology indicates the client is prepared for the examination, which ensures the test can be conducted smoothly.
Rationale:
A: Holding the client's morning bronchodilator medication may impact test results, but this information is more relevant for the healthcare provider interpreting the results, not the respiratory therapist conducting the test.
C: Physical therapy's statement about running on a treadmill is irrelevant to the PFTs and does not impact the collaboration between the nurse and respiratory therapist.
D: Advising the client not to smoke for 6 hours prior to the test is important for accurate results, but this information is more pertinent for the client and healthcare provider interpreting the results, not the respiratory therapist conducting the test.