Nursing Elites

1. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

2. A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?

• A. Assistance with activities of daily living.
• B. Daily physical therapy activities.
• C. Oxygen therapy at 2 liters per nasal cannula.
• D. Complete bedrest with frequent repositioning.

Correct answer: A

Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.

3. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?

• A. Assess the client's lung sounds.
• B. Assign a different UAP to the client.
• C. Report the UAP to the manager.
• D. Request thicker liquids for meals.

Correct answer: A

Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.

4. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

• A. Blockage of the ET tube by the client's tongue
• B. Passage of the ET tube into the esophagus
• C. Movement of the ET tube into the right main bronchus
• D. Infection of the vocal cords

Correct answer: C

Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.

5. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?

• A. African American churches
• B. Asian American groceries
• C. High school sports camps
• D. Women's health clinics

Correct answer: A

Rationale: The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.

Similar Questions