The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

Initiate and maintain supplemental oxygen as prescribed.

Plan activities with rest periods to conserve oxygen needs.

Provide nasotracheal suctioning as needed to remove secretions.

Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

Answer and Explanation

The Correct Answer is C

A. Initiate and maintain supplemental oxygen as prescribed: Supplemental oxygen helps improve oxygenation but does not directly address the underlying issue of retained secretions. Oxygen delivery is important, but secretion removal is the priority when the airway is obstructed.

B. Plan activities with rest periods to conserve oxygen needs: While energy conservation is useful for managing oxygen demand in alert clients, it does not apply to an unresponsive client. Additionally, it does not assist with clearing the airway or managing retained secretions.

C. Provide nasotracheal suctioning as needed to remove secretions: Suctioning is the most appropriate intervention for an unresponsive client with retained secretions, as they are unable to cough or clear their own airway. This intervention directly supports airway clearance and improves ventilation.

D. Monitor oxygenation (the oxygen saturation [SaO2]) during activity: Monitoring oxygen saturation is helpful for evaluating respiratory status, but this intervention does not address the immediate problem of retained secretions compromising airway clearance.

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Correct Answer is ["3"]

Explanation

Children with the common cold are generally most contagious during the early stages of the illness typically within the first 2 to 3 daysafter symptoms appear. This is when viral shedding is at its peak, even if the child’s symptoms are mild. Hand hygiene, covering coughs, and limiting contact with others during the early days are essential to prevent spread.

A. Record the amount of blood loss B. Ask about the last episode of bleeding and how long it took to stop. C. Check the client's vital signs D. Inquire if the client had a headache along with the bleeding.

Correct Answer is C

Explanation

A. Record the amount of blood loss:While important for documentation, patients often cannot accurately estimate blood loss, especially with nasal bleeding. This step is secondary to assessing the client’s current physiological status following multiple episodes.

B. Ask about the last episode of bleeding and how long it took to stop:This can provide useful information for identifying patterns, but it does not assess the client’s immediate condition or potential complications like hypovolemia or hypertension.

C. Check the client's vital signs:Vital signs offer immediate insight into the client’s circulatory and respiratory status. Multiple episodes of epistaxis in one day could indicate hemodynamic instability or uncontrolled hypertension, making this the priority assessment.

D. Inquire if the client had a headache along with the bleeding:A headache could be associated with elevated blood pressure or sinus involvement, but it is not the most urgent concern after repeated nosebleeds. Assessing vital signs takes precedence.

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The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

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Naxlex Comprehensive Predictor Exams

The mother of a child with a cold asks the nurse. "How long will my child be contagious?". The nurse should reply?

Correct Answer is ["3"]

Explanation

A 55-year-old man presents to the health nurse at his workplace with epistaxis. He reports he has had four nosebleeds today, and he is concerned because he can usually control the bleeding himself. What would be the most helpful assessment after the nurse has stopped the bleeding?

Correct Answer is C

Explanation

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