Nokea
While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?
- A. Ask the mother what she usually uses on the child's lips and nose.
- B. Apply a petroleum jelly (Vaseline) to the child's nose and lips.
- C. Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips.
- D. Use a water-soluble lubricant on affected oral and nasal mucosa.
Correct Answer: D
Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.
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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.
The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?
- A. Slight difficulty swallowing
- B. Hoarse voice
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct Answer: C
Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.
A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. Liver function tests
- B. Complete blood count
- C. Serum creatinine
- D. Prothrombin time
Correct Answer: C
Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Inspiratory crackles
Correct Answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.
During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?
- A. Infection
- B. Hypoxia
- C. Bleeding
- D. Bronchospasm
Correct Answer: A
Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.