Nokea
Which nursing intervention can help a client avoid dealing simultaneously with multiple stimuli?
- A. Reducing activity
- B. Touching the client as often as possible
- C. Increasing bright lights
- D. Taking a position as close to the client as possible
Correct Answer: A
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 receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct Answer: D
Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications.
A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease.
B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action.
C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.
During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem?
- A. Obesity
- B. Dehydration
- C. Enlarged liver
- D. Decreased peripheral pulses
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nursing student asks what essential hypertension is. What response by the registered nurse is best?
- A. It means it is caused by another disease.
- B. It means it is essential that it be treated.
- C. It is hypertension with no specific cause.
- D. It refers to severe and life-threatening hypertension.
Correct Answer: C
Rationale: The correct answer is C: It is hypertension with no specific cause.
Rationale:
1. Essential hypertension is also known as primary or idiopathic hypertension.
2. It is the most common type of hypertension, accounting for about 90-95% of cases.
3. The exact cause of essential hypertension is unknown, but it is believed to be due to a combination of genetic, environmental, and lifestyle factors.
4. Choices A, B, and D are incorrect because essential hypertension is not caused by another disease, does not necessarily require treatment as essential means "fundamental," and is not specifically severe or life-threatening.
A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Use of accessory muscles
- D. Silent chest
Correct Answer: D
Rationale: The correct answer is D: Silent chest. This finding indicates severe airway obstruction and impending respiratory failure, requiring immediate intervention to prevent respiratory arrest. Silent chest means minimal or absent breath sounds, suggesting no air movement, which is a critical emergency situation. Wheezing (A), increased respiratory rate (B), and use of accessory muscles (C) are common in asthma attacks but do not indicate as severe a condition as a silent chest. Monitoring and addressing a silent chest promptly is crucial in managing acute asthma exacerbations.
What should the nurse request Mr. Ross to do while assisting him to cough and deep breathe postoperatively?
- A. Request him to splint his incision with his hand or a pillow
- B. Ask him to relax his abdominal muscles
- C. Place him in a supine position
- D. Encourage him to limit his chest expansion upon inspiration
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.