Nokea
You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
- A. Easily fatigued with physical activity
- B. Reduced peak flow meter reading
- C. Chest retractions
- D. Cyanosis
- E. Wheezing with activity
- F. Nighttime coughing
- G. No relief with short-acting bronchodilator inhaler
Correct Answer: A,B,E,F
Rationale: Early warning signs include fatigue, reduced peak flow, wheezing with activity, and nighttime coughing. Chest retractions, cyanosis, and no relief from a bronchodilator indicate a more severe attack.
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You're developing a plan of care for a patient who is at risk for the development of a deep vein thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient's plan of care to prevent DVT formation?
- A. The patient will eat all meals out of the bed daily by sitting in the bedside chair.
- B. The nurse will apply sequential compression devices (SCDs) per physician's order to the patient's lower extremities every night at bedtime.
- C. The nurse will administer per physician's order Enoxaparin in the subcutaneous tissue of the abdomen.
- D. The patient will ambulate daily.
Correct Answer: B
Rationale: Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting. The only time a patient should not wear the SCDs is when they're ambulating. Therefore, the nurse would NOT just apply them at bedtime but during the day too.
The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
- A. Assess respiratory rate and depth.
- B. Provide for adequate rest period.
- C. Administer oxygen as prescribed.
- D. Teach slow abdominal breathing.
Correct Answer: C
Rationale: Administering oxygen as prescribed (C) is the priority for bacterial pneumonia to address hypoxemia, a common issue due to impaired gas exchange. Assessing respiratory rate (A) is important but secondary to ensuring oxygenation. Rest (B) and breathing techniques (D) support recovery but are not the first priority.
Which nursing action is essential before suctioning the client with a tracheostomy tube?
- A. Preoxygenating the client
- B. Maintaining the head in a flexed position
- C. Cleaning around the stoma
- D. Removing the inner cannula
Correct Answer: A
Rationale: Preoxygenating the client prevents hypoxia during suctioning, which can temporarily reduce oxygen intake.
Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply.
- A. Perform postural drainage and percussion every four (4) hours.
- B. Modify activities to accommodate daily physiotherapy.
- C. Increase fluid intake to one (1) liter daily to thin secretions.
- D. Recognize and report signs and symptoms of respiratory infections.
- E. Avoid anyone suspected of having an upper respiratory infection.
Correct Answer: A,B,D,E
Rationale: Postural drainage (1) helps clear mucus in CF. Modifying activities for physiotherapy (2) ensures adherence. Recognizing infection signs (4) and avoiding respiratory infections (5) prevent exacerbations. One liter of fluid (3) is insufficient for children; fluid needs vary by age and size.
To prevent the client with a head cold from developing a secondary ear infection, which recommendation is most appropriate?
- A. Sleeping with the head elevated
- B. Blaving the nose very gently
- C. Inserting cotton into the ears
- D. Massaging the area behind the ears
Correct Answer: B
Rationale: Blowing the nose gently prevents excessive pressure in the Eustachian tubes, which can lead to fluid buildup and secondary ear infections.