When a patient has been extubated from the ventilator after cardiac surgery, the nurse encourages the patient to:
A) Deep breathe and cough at least every 1 to 2 hours
B) Deep breathe and cough once every 6 hours
C) Lie flat as often as possible
D) Avoid taking deep breaths to minimize pain
Ans: A
Feedback: Deep breathing and forced expiration technique or coughing should be encouraged every 1 to 2 hours at least. This opens the alveolar sacs and provides increased perfusion. Less frequent intervals and lying flat for extended periods increase chances of pooled secretions and minimal alveolar expansion.
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The nurse is taking a health history of a 15-month-old boy who is not yet speaking. Which of the following findings is not a risk factor for a possible genetic disorder?
A) The child is of male gender and Caucasian race. B) The grandmother and father had hearing impairments. C) The child was a breech delivery 3 weeks early. D) The mother was 37 when she became pregnant.
The nurse is using a tool to assess the quality of life of a hospice patient. The nurse addresses the appropriate areas of concern when asking which of the following questions? (Select all that ap-ply.)
a. "Are you able to bathe yourself?" b. "Did your grandson get the grass cut like he planned?" c. "How would you rate your pain on a scale of 1 to 10?" d. "Do you still have concerns about your will?" e. "Can we talk about why you never remar-ried?"
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first?
A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client's overall intake and output record D. Administer a 250-mL bolus of normal saline solution (0.9%
The licensed practical/vocational nurse was caring for a client in a nursing home who has end-stage cancer and recently had a debilitating stroke (brain attack). On several occasions, nurses reported the client stated he wished he was dead
One night the client arrested. The client was a full code. When the licensed practical/vocational nurse found him, she called a code blue. The staff took their time to respond and even longer to call "911." Which exemplifies the third step in the process of ethical decision making for this situation? A) A client is at the end of his life and has verbalized that he wished he was dead. B) Is a slow code acceptable when the client stated he wished he was dead, or should he have made the choice known and secured an order for "do not resuscitate," and since he did not, the nurses are bound to resuscitate quickly? C) Facts: the client has end-stage cancer and a debilitating stroke decreasing quality of life. Hearsay: In several occasions the client has stated he wished he was dead. Rumors: The man deserves to join his wife in heaven; he has no family left. Emotional components: The nurses feel they would want to not be resuscitated if they were in the client's shoes. D) Action A: Slow code and call "911" late into the code—client dies; nurses feel guilty because of legal/ethical obligations. Action B: Perform the code quickly and client may live—no change in quality of life; may have ability to secure a "do not resuscitate" order in future. Action C: Perform the code quickly and client may die—client ends poor quality of life.