A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

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Fundamentals of Nursing Oxygenation Practice Questions Questions

Question 1 of 5

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

Correct Answer: B

Rationale: Padded boots prevent foot drop in immobile clients. Ulcers (A) require pressure relief. Pooling (C) and BP changes (D) are unrelated.

Question 2 of 5

A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse concern?

Correct Answer: C

Rationale: Ventricular tachycardia is a potentially fatal dysrhythmia requiring immediate intervention due to ineffective cardiac output. Sinus rhythm is normal, atrial fibrillation is manageable, and premature atrial contractions are typically benign.

Question 3 of 5

A patient with a history of smoking reports shortness of breath. Which condition is most likely?

Correct Answer: B

Rationale: Emphysema, a COPD type, is strongly linked to smoking and causes shortness of breath due to alveolar destruction, unlike asthma (allergy-related), pneumothorax (lung collapse), or pulmonary edema (fluid-related).

Question 4 of 5

A patient with a chest tube reports sudden dyspnea. What is the priority action?

Correct Answer: A

Rationale: Sudden dyspnea with a chest tube suggests blockage or disconnection. Checking patency ensures proper lung re-expansion and oxygenation, taking priority over pain meds, oxygen increase, or repositioning.

Question 5 of 5

A nurse is preparing a patient for a thoracentesis. What is the priority nursing action?

Correct Answer: B

Rationale: Positioning the patient upright facilitates fluid drainage during thoracentesis and ensures safety, taking priority over monitoring BP, sedation, or checking saturation initially.

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