Nokea
Which intervention can help a visually impaired client achieve independence?
- A. Keep personal care items in a different location each day
- B. Ask the client’s preference for where to store hygiene articles and other objects needed for self-care
- C. At mealtimes, ask the client to feel where food is on the plate
- D. Place meal tray on overbed tray and leave the room
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding does the nurse expect?
- A. Increased anteroposterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anteroposterior (AP) chest diameter. In COPD, the chronic obstruction of airflow leads to air trapping in the lungs, causing the chest to expand more front-to-back (increased AP diameter). This is known as "barrel chest" and is a characteristic finding in COPD due to hyperinflation of the lungs.
Incorrect choices:
B: Decreased respiratory rate is not expected in COPD as patients may have increased respiratory rate due to difficulty breathing.
C: Weight gain is not a typical finding in COPD as patients often experience weight loss due to increased energy expenditure and decreased appetite.
D: Productive cough with yellow sputum is common in COPD, but it is not the most specific finding for this condition.
A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
- A. Administer albuterol treatment.
- B. Notify Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.
A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?
- A. Initiate oxygen therapy at 2 liters per minute via nasal cannula.
- B. Place the client in a high-Fowler's position.
- C. Notify the healthcare provider.
- D. Document the finding in the client's medical record.
Correct Answer: A
Rationale: The correct answer is A: Initiate oxygen therapy at 2 liters per minute via nasal cannula. Oxygen saturation of 88% indicates hypoxemia and requires immediate intervention. Providing supplemental oxygen via nasal cannula will help improve oxygenation. Placing the client in high-Fowler's position may help with ventilation but addressing hypoxemia is the priority. Notifying the healthcare provider is important but immediate intervention is necessary. Documenting the finding is important but should not delay providing oxygen therapy.
A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?
- A. Production of pink sputum
- B. Tracheal deviation
- C. Drainage greater than 70 mL/hr
- D. Sudden onset of shortness of breath
Correct Answer: B
Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent respiratory compromise. The other choices are incorrect because:
A: Production of pink sputum may indicate bleeding but does not require immediate intervention unless severe.
C: Drainage greater than 70 mL/hr may indicate a potential issue with the chest tube, but it does not require immediate intervention unless accompanied by other symptoms.
D: Sudden onset of shortness of breath is concerning but not as immediately life-threatening as tracheal deviation in this context.
Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.