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When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to:
- A. Avoid smoking near the client.
- B. Turn off oxygen during meals.
- C. Adjust the liter flow to 10 as needed.
- D. Remind the client to keep mouth closed.
Correct Answer: A
Rationale: Smoking near oxygen poses a fire hazard and exacerbates respiratory issues.
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What are manifestations of obsessive-compulsive disorder?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: A
Rationale: The correct answer is A because it is the most appropriate response based on physiological and medical principles.
A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation & hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, influencing their respiratory status. The healthcare professional needs to assess potential respiratory risks in the client's environment.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference is more relevant for assessing risk of obstructive sleep apnea rather than overall respiratory status.
C: Height & weight are important for assessing overall health and potential respiratory issues like obesity, but not as immediate as assessing respiratory hazards in the client's daily activities.
Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is
- A. vital signs.
- B. surgical site.
- C. respiratory adequacy.
- D. level of consciousness.
Correct Answer: C
Rationale: Respiratory adequacy is critical immediately postoperatively to ensure oxygenation and ventilation.
A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:
- A. he should not be concerned, because it will be quickly resolved.
- B. urinary incontinence is usually temporary.
- C. he should notify the nurse when this happens.
- D. this is related to the bladder spasms and will soon stop.
Correct Answer: B
Rationale: Urinary incontinence is usually temporary, but the problem may take some time to resolve, especially in an older male. Bladder spasms are not the cause of the client's incontinence.
When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)
- A. Cost-saving measures
- B. Nurse's expertise
- C. Client preferences
- D. Research findings
Correct Answer: A
Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.