A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?

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Question 1 of 9

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?

Correct Answer: A

Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.

Question 2 of 9

Your patient is a 25-year-old woman just diagnosed with hydatidiform mole. You would expect:

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 9

A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

Correct Answer: B

Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.

Question 4 of 9

Why is the potential for death from infections with multidrug-resistant microorganisms increased?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 9

Why should a nurse use affective touching cautiously?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 6 of 9

A healthcare provider collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the healthcare provider include in communications with the respiratory therapist prior to the tests? (Select ONE that does not apply)

Correct Answer: C

Rationale: Correct Answer: C Rationale: - Option C, stating that physical therapy has approved the client for treadmill exercise, is unrelated to pulmonary function tests (PFTs). PFTs measure lung function, not physical therapy or exercise tolerance. - Options A, B, and D are all essential for accurate PFT results. A) Ensuring the client did not use bronchodilators can affect test outcomes. B) The location for the examination is not relevant as long as the equipment is available. D) Instructing the client not to smoke before the test is crucial as smoking can affect lung function.

Question 7 of 9

What aspect should a nurse pay particular attention to when assessing a client with a potential or actual infection?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 8 of 9

Which set of classification values indicates the most extensive and progressed cancer?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 9 of 9

You are caring for a patient with an infected wound. You would expect

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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