Nokea
Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. Bradypnea, or slow breathing, is a critical finding that can indicate respiratory compromise and potentially lead to respiratory failure. It requires immediate attention to prevent further deterioration.
Constipation (A) is important but not as urgent as addressing a respiratory issue. Sedation (B) and euphoria (D) are side effects that may need monitoring but do not pose immediate threats to the patient's health.
In summary, addressing bradypnea is the priority to ensure the patient's respiratory function and prevent a life-threatening situation.
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Select the 5 actions the nurse should take.
- A. Provide frequent rest periods for the client.
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions
- D. Place the client on a low-carbohydrate diet
- E. Place the client under contact isolation.
- F. Instruct the client to avoid blowing their nose forcefully
- G. Assess the client's level of orientation
Correct Answer: A,B,C,E,F,G
Rationale: The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Irrigate indwelling urinary catheter with 50 mL of normal saline:
- B. Administer enema to relieve constipation
- C. Maintain bed rest for 2 days postoperatively
- D. Place a blanket rob under the client's knees while in bed.
- E. Apply warm compresses to the incision site.
Correct Answer:
Rationale: Rationales provided within the question context.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure
- B. Instruct the client to avoid coughing during the procedure
- C. Inform the client that he will be NPO for 6 hr prior to the procedure
- D. Place the client in the prone position during the procedure,
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to avoid coughing during the procedure. This is crucial because coughing can disrupt the procedure, leading to potential complications. Coughing can cause movement that may interfere with the accuracy of the procedure or cause injury to the client. Positioning the client on the affected side (A) for 4 hours following the procedure is not necessary and can lead to discomfort. Informing the client that they will be NPO for 6 hours prior to the procedure (C) may not be relevant depending on the type of procedure. Placing the client in the prone position during the procedure (D) can be risky and uncomfortable for the client.
The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Chorioamnionitis
- B. Maternal fever
- C. Fetal anemia
- D. Maternal hypoglycemia
Correct Answer: D
Rationale: Maternal hypoglycemia can lead to fetal bradycardia.