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Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.
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Which observation best indicates that a client with a pneumothorax is developing a tension pneumothorax?
- A. The trachea is deviated.
- B. The client is coughing.
- C. The chest is asymmetrical.
- D. The client reports sharp pain.
Correct Answer: A
Rationale: Tracheal deviation is a hallmark sign of tension pneumothorax, indicating mediastinal shift due to increased intrathoracic pressure.
After the client receives the weekly injection, which nursing instruction is essential?
- A. Take a couple of aspirin before leaving.
- B. Wait at least 30 minutes before leaving.
- C. Make sure someone else drives the car.
- D. Avoid getting the injection site wet.
Correct Answer: B
Rationale: Clients must wait at least 30 minutes after an allergy injection to monitor for potential allergic reactions, such as anaphylaxis.
A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed?
- A. Macrolide
- B. Cephalosporins
- C. Pencillin G
- D. Tamiflu
Correct Answer: A
Rationale: For gram-positive bacterial pneumonia in a penicillin-allergic patient, macrolides like azithromycin are commonly prescribed due to their efficacy and safety. Cephalosporins may cross-react with penicillin allergies, Penicillin G is contraindicated, and Tamiflu is for viral infections.
To prevent the client with a head cold from developing a secondary ear infection, which recommendation is most appropriate?
- A. Sleeping with the head elevated
- B. Blaving the nose very gently
- C. Inserting cotton into the ears
- D. Massaging the area behind the ears
Correct Answer: B
Rationale: Blowing the nose gently prevents excessive pressure in the Eustachian tubes, which can lead to fluid buildup and secondary ear infections.
The term 'blue bloaters' is used to describe patients with?
- A. Pulmonary hypertension
- B. Left-sided heart failure
- C. Chronic Bronchitis
- D. Emphysema
Correct Answer: C
Rationale: Blue bloaters' describes chronic bronchitis patients, who present with cyanosis ('blue') and edema ('bloating') due to hypoxemia and right heart failure. Emphysema patients are often called 'pink puffers.'