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Which of the ff is an assessment finding in a client with bonchiectasis?
- A. Same amount of sputum at all stages of the disease
- B. Non productive cough
- C. Expectoration of small amounts of sputum
- D. Worsening cough with position changes
Correct Answer: D
Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.
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An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues.
A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care.
B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications.
C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D.
Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
- A. Epinephrine
- B. 50% dextrose
- C. Glucagon
- D. Hydrocortisone
Correct Answer: C
Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.
A nurse is discharging a client from the hospital. When should discharge planning be initiated?
- A. At the time of discharge from an acute health care setting
- B. At the time of admission to an acute health care setting
- C. Before admission to an acute health care setting
- D. When the client is at home after acute care
Correct Answer: B
Rationale: Rationale:
1. Discharge planning should start at admission to ensure comprehensive preparation.
2. Early planning allows for assessment of needs and coordination of resources.
3. It promotes continuity of care and reduces risks of readmission.
4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
- A. New set of tracheostomy tubes and Oxygen tank
- B. Theophylline and Epinephrine
- C. Obturator and Kelly clamp
- D. Sterile saline dressing
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank.
Rationale:
1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway.
2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted.
Summary of incorrect choices:
B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy.
C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation.
D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC’s color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: D
Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure.
Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling.
Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications.
Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.