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Which is an important nursing consideration when suctioning a young child who has had heart surgery?
- A. Perform suctioning at least every hour.
- B. Suction for no longer than 30 seconds at a time.
- C. Administer supplemental oxygen before and after suctioning.
- D. Expect symptoms of respiratory distress when suctioning.
Correct Answer: B
Rationale: Suctioning for no longer than 30 seconds at a time is an important nursing consideration when suctioning a young child who has had heart surgery. Prolonged suctioning can cause hypoxemia and decrease the child's oxygen saturation, which can be detrimental, especially in postoperative patients who may have compromised cardiopulmonary reserves. It is crucial to minimize the duration of suctioning to prevent potential complications. Additionally, hyperoxygenation before and after suctioning may help maintain adequate oxygen levels and minimize the risk of hypoxemia in these vulnerable patients.
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A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in
- B. Irregular heart rate of 82 beats/min
- C. Pupils constricted and equal
- D. Respiratory rate of 8breaths/min
Correct Answer: D
Rationale: The assessment finding that suggests the client is experiencing an adverse effect of morphine (Duramorph) is a respiratory rate of 8 breaths/min. Morphine is a potent opioid analgesic that can cause respiratory depression as a side effect. When the respiratory rate decreases significantly, it indicates the potential for compromised breathing, which could progress to respiratory failure. This is a serious adverse effect that requires immediate attention and evaluation by healthcare providers. The client receiving continuous infusion of morphine should be closely monitored for signs of respiratory depression to prevent life-threatening consequences.
A patient asks how to avoid lung cancer. The following are risk factors, except:
- A. Exposure to passive smoke
- B. Crowded living conditions
- C. Air pollution
- D. Diet low in fruits and vegetables
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following is the most common symptoms of pericarditis?
- A. Dyspnea c.Chest pain
- B. Intermittent claudication
- C. Calf pain
Correct Answer: A
Rationale: The most common symptom of pericarditis is chest pain. This chest pain is typically sharp and stabbing, and it may worsen when taking deep breaths or lying down. It can also be relieved by sitting up or leaning forward. Other symptoms of pericarditis may include dyspnea (shortness of breath), but chest pain is the hallmark symptom that differentiates pericarditis from other conditions. Intermittent claudication and calf pain are not typically associated with pericarditis.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: It is crucial to give the patient with aphasia time to complete their sentence. Aphasia can impact a person's ability to find the right words, so allowing them the time to express themselves can be helpful. Rushing or providing excessive cues could lead to frustration and may not allow the patient the opportunity to find the appropriate words on their own. Being patient and giving the individual time to communicate can be empowering and supportive.