Nokea
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.
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Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.
Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.
Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.
Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
- A. Consult physical therapy.
- B. Establish a new plan of care.
- C. Set new priorities for the patient.
- D. Assess the patient.
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client’s diet
- B. The client’s family member’s history of
- C. The client’s drug history chronic diseases
- D. The client’s ability to produce antibodies
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points.
A: Massaging reddened areas can worsen the condition by increasing friction and pressure.
B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective.
D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. “Anemia prevents your lungs from absorbing oxygen effectively.”
- B. “You do not have enough hemoglobin to carry oxygen to your tissues.”
- C. “”You don’t have enough blood to feed your cells.”
- D. “You have lost a lot of blood, and that has damaged your lungs.”
Correct Answer: B
Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.