NUR202: Ch. 28 & Ch. 29

A nurse working in a geriatric clinic sees clients with “cold” symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?

• • Teach the client about possible drowsiness.

• • Instruct the client to drink plenty of water.

• • Consult with the PHCP about the medication.

• • Encourage the client to take the medication with food.

The charge nurse on a medical unit is preparing to admit several “clients” who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

• • Admit the “clients” on Contact Precautions.

• • Inquire as to recent travel outside the United States.

• • Do not allow pregnant caregivers to care for these “clients.”

• • Place the “clients” on enhanced Droplet Precautions.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying “I have been drinking tons of water. How am I dehydrated?” What response by the nurse is best?

• • “Breathing so quickly can be dehydrating.”

• • “Everyone with pneumonia is dehydrated.”

• • “This is really just to administer your antibiotics.”

• • “Why do you think you are so dehydrated?”

Tags

NGSS.HS-LS1-3

A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)?

• • Encourage between-meal snacks.

• • Monitor temperature every 4 hours.

• • Provide oral care every 4 hours.

• • Report any new onset of cough.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

• • Community social worker for Meals on Wheels

• • Occupational therapy for job retraining

• • Physical therapy for homebound therapy services

• • Visiting nurses for directly observed therapy

The emergency department nurse is participating in a bioterrorism drill in which several “clients” are suspected to have inhalation anthrax. Which “clients” would the nurse see as the priorities? (Select all that apply.)

• • Widened mediastinum on chest x-ray

• • Stridor

• • Oxygen saturation of 91%

• • Diaphoresis

• • Oral temperature of 99.9° F (37.7° C)

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority?

• • Assess the client’s lung sounds.

• • Notify the Rapid Response Team.

• • Provide reassurance to the client.

• • Take a full set of vital signs.

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client’s oxygen saturation has not significantly improved. What response by the nurse is best?

• • “Breathing so rapidly interferes with oxygenation.”

• • “Maybe the client has respiratory distress syndrome.”

• • “The blood clot interferes with perfusion in the lungs.”

• • “The client needs immediate intubation and mechanical ventilation.”

A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best?

• • Ensure that the client has adequate sedation.

• • Find another qualified provider to intubate.

• • Interrupt the procedure to give oxygen.

• • Monitor the client’s oxygen saturation.

A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)?

• • Assess the client for sedation needs.

• • Get family permission for restraints.

• • Provide frequent oral care per protocol.

• • Use nonverbal pain assessment tools.