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While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
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In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client's oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct Answer: C
Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.
When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?
- A. Yes, I have. Do you have some questions about dying?
- B. Several times. Now, let's get your dressing changed.
- C. A few times. It was peaceful and there was no pain.
- D. Yes, but you're doing great. Are you concerned about dying?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and encourages open communication. The nurse acknowledges the client's question and offers support by asking if they have any concerns. This response demonstrates active listening and shows the nurse is willing to address the client's emotional needs.
Choice B is incorrect as it dismisses the client's question and focuses solely on the task at hand, lacking empathy. Choice C is incorrect as it provides a general statement about previous experiences without directly addressing the client's inquiry. Choice D is incorrect as it deflects the question and does not actively engage with the client's emotional concerns.
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push effectively to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.