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While you are talking with the patient, she becomes confused and begins slurring her words. What would you expect the physician to do?
- A. Assess if the patient had an ischemic or hemorrhagic cerebral vasospasm (CVS).
- B. Administer thrombolytic agent (TPA) since this is within 3 hours of the cerebrovascular accident (CVA).
- C. Tell the patient to go home, get rest, and to call the physician in the morning if the symptoms continue.
- D. Admit the patient and place her on bed rest.
Correct Answer: B
Rationale: Thrombolytics can dissolve clots if administered within the therapeutic window.
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What should the nurse do while dealing with older adults who lose the ability to hear at high-pitched ranges?
- A. Lower the voice pitch.
- B. Insert a stethoscope in the client’s ears.
- C. Use a magic slate or chalkboard.
- D. Ensure that the hearing aid is in good working order.
Correct Answer: A
Rationale: Lowering the voice pitch accommodates age-related hearing loss, improving communication clarity.
A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?
- A. Label the catheter as an epidural access
- B. Assess the patient’s pain relief frequently
- C. Use sterile technique when caring for the catheter
- D. Monitor the patient’s level of consciousness (LOC)
Correct Answer: B
Rationale: The correct answers are B. All listed actions are essential for safe and effective care.
Which are implications of stress?
- A. Valvular conditions
- B. Inflammatory GI disorders
- C. Fluid imbalance
- D. Electrolyte imbalance
Correct Answer: B
Rationale: Stress can lead to gastrointestinal inflammation, which may manifest as ulcers, irritable bowel syndrome, or other digestive issues.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to:
- A. Avoid smoking near the client.
- B. Turn off oxygen during meals.
- C. Adjust the liter flow to 10 as needed.
- D. Remind the client to keep mouth closed.
Correct Answer: A
Rationale: Smoking near oxygen poses a fire hazard and exacerbates respiratory issues.
A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I plan to wear my oxygen when I exercise & feel short of breath.
- B. I will use my portable oxygen when grilling burgers in the backyard.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will only smoke while I am wearing my oxygen via nasal cannula.
Correct Answer: C
Rationale: The correct answer is C because using cotton balls to cushion the oxygen tubing on the ears helps prevent skin irritation or pressure ulcers. This indicates the client understands the importance of skin care and comfort while using oxygen therapy.
A: Incorrect. The client should wear oxygen during all activities that increase oxygen demand, not just when feeling short of breath during exercise.
B: Incorrect. Using portable oxygen near an open flame like a grill can result in a fire hazard.
D: Incorrect. Smoking while using oxygen therapy is extremely dangerous and can lead to a fire.