A nurse answers a call light and finds a client anxious, short of breath, reporting chest
pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What
action by the nurse takes priority?
a.Assess the client's lung sounds
.b.Notify the Rapid Response Team.
c.Provide reassurance to the client.
d.Take a full set of vital signs.
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, .b.Notify the Rapid Response Team.
This client has manifestations of a pulmonary embolism, and the most
critical action is to notify the Rapid Response Team for speedy diagnosis
and treatment. The other actions are appropriate also but are not the
priority.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral
lesions. Which action should the nurse take?
a. Encourage oral rinsing after fluticasone administration.
b. Obtain an oral specimen for culture and sensitivity.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.
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a. Encourage oral rinsing after fluticasone administration.
The drug reduces local immunity and increases the risk for local infection,
especially Candida albicans. Rinsing the mouth after using the inhaler will
decrease the risk for developing this infection. Use of mouthwash and
broad-spectrum antibiotics is not warranted in this situation. The nurse
should document the finding, but the best action to take is to have the
client start rinsing his or her mouth after using fluticasone. An oral
specimen for culture and sensitivity will not provide information necessary
to care for this client.
The nurse is caring for a client with lung cancer who states, "I don't want any pain
medication because I am afraid I'll become addicted." How should the nurse
respond?
a. "I will ask the provider to change your medication to a drug that is less potent."
b. "Would you like me to use music therapy to distract you from your pain?"
c. "It is unlikely you will become addicted when taking medicine for pain."
d. "Would you like me to give you acetaminophen (Tylenol) instead?"
,Give this one a try later!
c. "It is unlikely you will become addicted when taking medicine for pain."
Clients should be encouraged to take their pain medications; addiction
usually is not an issue with a client in pain. The nurse would not request that
the pain medication be changed unless it was not effective. Other methods
to decrease pain can be used, in addition to pain medication
A nurse teaches a client who is interested in smoking cessation. Which statements
should the nurse include in this client's teaching? (Select all that apply.)
a. "Find an activity that you enjoy and will keep your hands busy."
b. "Keep snacks like potato chips on hand to nibble on."
c. "Identify a punishment for yourself in case you backslide."
d. "Drink at least eight glasses of water each day."
e. "Make a list of reasons you want to stop smoking."
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a. "Find an activity that you enjoy and will keep your hands busy."
d. "Drink at least eight glasses of water each day."
e. "Make a list of reasons you want to stop smoking."
The nurse should teach a client who is interested in smoking cessation to
find an activity that keeps the hands busy, to keep healthy snacks on hand
to nibble on, to drink at least 8 glasses of water each day, and to make a list
of reasons for quitting smoking. The nurse should also encourage the client
not to be upset if he or she backslides and has a cigarette.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which
action should the nurse take first?
a. Document the findings.
, b. Administer oxygen therapy.
c. Position the client in high-Fowler's position.
d. Administer prescribed albuterol.
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a. Document the findings.
Bronchial breath sounds, including harsh, hollow, tubular, and blowing
sounds, are a normal finding over the trachea and larynx. The nurse should
document this finding. There is no need to implement oxygen therapy,
administer albuterol, or change the client's position because the finding is
normal.
Mechanical VentilationIndications for Use
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Surgical procedures
Decreased LOC
Post-op
Neuromuscular diseases
Spinal cord injury (SCI) or head injury (HI)
Drug overdose
Respiratory Failure
Multiple trauma or shock - ARDS
ARDS
Give this one a try later!
pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What
action by the nurse takes priority?
a.Assess the client's lung sounds
.b.Notify the Rapid Response Team.
c.Provide reassurance to the client.
d.Take a full set of vital signs.
Give this one a try later!
, .b.Notify the Rapid Response Team.
This client has manifestations of a pulmonary embolism, and the most
critical action is to notify the Rapid Response Team for speedy diagnosis
and treatment. The other actions are appropriate also but are not the
priority.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral
lesions. Which action should the nurse take?
a. Encourage oral rinsing after fluticasone administration.
b. Obtain an oral specimen for culture and sensitivity.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.
Give this one a try later!
a. Encourage oral rinsing after fluticasone administration.
The drug reduces local immunity and increases the risk for local infection,
especially Candida albicans. Rinsing the mouth after using the inhaler will
decrease the risk for developing this infection. Use of mouthwash and
broad-spectrum antibiotics is not warranted in this situation. The nurse
should document the finding, but the best action to take is to have the
client start rinsing his or her mouth after using fluticasone. An oral
specimen for culture and sensitivity will not provide information necessary
to care for this client.
The nurse is caring for a client with lung cancer who states, "I don't want any pain
medication because I am afraid I'll become addicted." How should the nurse
respond?
a. "I will ask the provider to change your medication to a drug that is less potent."
b. "Would you like me to use music therapy to distract you from your pain?"
c. "It is unlikely you will become addicted when taking medicine for pain."
d. "Would you like me to give you acetaminophen (Tylenol) instead?"
,Give this one a try later!
c. "It is unlikely you will become addicted when taking medicine for pain."
Clients should be encouraged to take their pain medications; addiction
usually is not an issue with a client in pain. The nurse would not request that
the pain medication be changed unless it was not effective. Other methods
to decrease pain can be used, in addition to pain medication
A nurse teaches a client who is interested in smoking cessation. Which statements
should the nurse include in this client's teaching? (Select all that apply.)
a. "Find an activity that you enjoy and will keep your hands busy."
b. "Keep snacks like potato chips on hand to nibble on."
c. "Identify a punishment for yourself in case you backslide."
d. "Drink at least eight glasses of water each day."
e. "Make a list of reasons you want to stop smoking."
Give this one a try later!
a. "Find an activity that you enjoy and will keep your hands busy."
d. "Drink at least eight glasses of water each day."
e. "Make a list of reasons you want to stop smoking."
The nurse should teach a client who is interested in smoking cessation to
find an activity that keeps the hands busy, to keep healthy snacks on hand
to nibble on, to drink at least 8 glasses of water each day, and to make a list
of reasons for quitting smoking. The nurse should also encourage the client
not to be upset if he or she backslides and has a cigarette.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which
action should the nurse take first?
a. Document the findings.
, b. Administer oxygen therapy.
c. Position the client in high-Fowler's position.
d. Administer prescribed albuterol.
Give this one a try later!
a. Document the findings.
Bronchial breath sounds, including harsh, hollow, tubular, and blowing
sounds, are a normal finding over the trachea and larynx. The nurse should
document this finding. There is no need to implement oxygen therapy,
administer albuterol, or change the client's position because the finding is
normal.
Mechanical VentilationIndications for Use
Give this one a try later!
Surgical procedures
Decreased LOC
Post-op
Neuromuscular diseases
Spinal cord injury (SCI) or head injury (HI)
Drug overdose
Respiratory Failure
Multiple trauma or shock - ARDS
ARDS
Give this one a try later!
