You are supervising an RN who was pulled from the medical-surgical floor to the emergency department (ED). The nurse is providing care for a client admitted with anterior epistaxis (nosebleed). Which of these directions will you clearly provide to the RN? (Choose all that apply.)

Correct Answer: D

Rationale: The correct answer includes B, C, and D. Applying direct pressure (B), maintaining universal precautions (C), and applying ice or cool compresses (D) are appropriate interventions for managing epistaxis. Positioning the client supine and turned on their side (A) is incorrect as it could lead to aspiration of blood.

Correct Answer: B

Rationale: In this scenario, the correct test that the nurse should plan to teach the patient about is option B) Spiral (helical) CT scan. This diagnostic test is the preferred method for diagnosing a pulmonary embolism due to its high sensitivity and specificity. A CT scan can visualize blood flow in the lungs and detect any blockages caused by a pulmonary embolus. Option A) Chest x-rays may show indirect signs of a pulmonary embolism, but they are not as sensitive or specific as a CT scan in diagnosing this condition. Option C) Taking the patient's pulse and blood pressure is important for assessing their vital signs, but it will not provide diagnostic information about a pulmonary embolism. Option D) Ventilation-perfusion lung scan is another imaging test used to diagnose a pulmonary embolism, but it is less commonly used compared to a CT scan due to limitations in sensitivity and specificity. In an educational context, it is crucial for nurses to understand the rationale behind selecting the most appropriate diagnostic test for a suspected condition. Teaching patients about the importance of diagnostic tests, their procedures, and possible outcomes empowers them to be active participants in their healthcare decisions and promotes better understanding and adherence to the treatment plan.

Correct Answer: A

Rationale: The correct answer is A: Assistance with activities of daily living. This intervention is appropriate because the client is experiencing dyspnea and reduced stamina, indicating potential limitations in performing daily activities independently. By providing assistance, the nurse can help conserve the client's energy and reduce the risk of exacerbating dyspnea. Physical therapy activities every day (B) may be too strenuous for a client experiencing dyspnea. Oxygen therapy at 2 liters per nasal cannula (C) is not the priority intervention without assessing the client's oxygen saturation levels. Complete bedrest with frequent repositioning (D) may lead to deconditioning and worsen dyspnea in the long term.

Correct Answer: B

Rationale: The correct answer is B: Excess lung inflation. The Hering Breuer Reflex is triggered by stretch receptors in the lungs, which send signals to the brain to inhibit further inhalation and prevent overinflation of the lungs. This mechanism helps regulate breathing and prevents lung damage from excessive stretching. Choices A, C, and D are incorrect because the reflex specifically focuses on preventing overinflation of the lungs, not tracheal collapsing or excess oxygenation. Therefore, the correct answer is B as it aligns with the protective function of the Hering Breuer Reflex.

Correct Answer: B

Rationale: Rationale for choice B (Hyperventilation): Hyperventilation leads to excessive elimination of carbon dioxide (CO2) through the lungs, causing a decrease in blood CO2 levels. This results in a shift towards alkalosis in the blood pH as CO2 is an acid. Acetazolamide, by inhibiting carbonic anhydrase, slows down the conversion of CO2 to bicarbonate, helping to counteract the alkalosis caused by hyperventilation. Summary of other choices: A (Hypoventilation): Hypoventilation would lead to the retention of CO2, causing respiratory acidosis, not alkalosis. C (Low Carbon dioxide level): Low CO2 levels contribute to respiratory alkalosis, so this choice is incorrect. D (High HB content): High hemoglobin content does not directly cause respiratory alkalosis.