Nokea
Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
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The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.
Which pulse oximetry reading indicates to the nurse that the client has normal tissue oxygenation?
- A. 80 to 90 mm Hg
- B. 95 to 100 mm Hg
- C. 80% to 85%
- D. 95% to 100%
Correct Answer: D
Rationale: A pulse oximetry reading of 95% to 100% indicates normal tissue oxygenation, reflecting adequate oxygen saturation.
Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?
- A. Airborne isolation.
- B. Droplet isolation.
- C. Reverse isolation.
- D. Strict isolation.
Correct Answer: A
Rationale: SARS is transmitted via respiratory droplets and possibly aerosols, requiring airborne isolation (A) with a negative pressure room and N95 masks. Droplet isolation (B) is insufficient for potential aerosol transmission. Reverse isolation (C) protects immunocompromised patients, not applicable here. Strict isolation (D) is not a standard term for SARS precautions.
The best evidence that the client understands the procedure for a pulmonary function test is when stating that it involves which action?
- A. Having an X-ray taken
- B. Drawing a blood specimen
- C. Breathing into a mouthpiece
- D. Examining expectorated sputum
Correct Answer: C
Rationale: Pulmonary function tests involve breathing into a mouthpiece to measure lung capacity and airflow.
Which statement by the client indicates an accurate understanding of the purpose of aerosol therapy?
- A. Aerosol therapy relieves tissue irritation.
- B. Aerosol therapy delivers medication directly to the lungs.
- C. Aerosolization dries respiratory passages.
- D. Aerosol therapy helps to slow breathing.
Correct Answer: B
Rationale: Aerosol therapy delivers medication directly to the lungs, targeting the respiratory tract for effective treatment of bronchitis.