Question

Suction the clients airway every two hours log roll the clients when turning side to side maintain the clients in a supine position offer the client an incentive spirometer every hour . The nurse works on a medical/ surgical units. she asks the UAP to ambulate a client recovering from hysterectomy. Two hours later, the Patient rings herBell and asked that and asked to be walked, claiming she has not seen the U AP this shift. The nurse finds UAP talking on his cell phone in the break room, which of the following action should the nurse take next? Remind th UAP of what the nurse asked her to do Demand the UAp gets off his cell phone while not on break fill out the incident report as soon as possible reports the U AP to the nursing supervisor Wout the inc AP sets off hisure asked her to . A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What should the nurse do when given this information? o use pre-warms test tubes keep The specimen out of light avoid use of a tourniquet during the procedure 0 place samples on Ice before sending to the lab 18. A patient with head trauma following a motor vehicle accident is on Mechanical ventilation with an endotracheal tube. which action by the nurse will reduce the risk for elevation in intracranial pressure during suctioning? o Avoid hyperoxygenating the patient before suctioning o Insert the suction catheter just to the end of the endotracheal tube apply suction while inserting the Catheter Limit suctioning to two times with each suctioning procedure 19. The nurse teaches a group of women about how to perform breast self examination, which instructions should the nurse include? Select all that apply while standing, press hands firmly into hips and bow slightly while seated, press hands together with fingers on one opposite those on the other hand while standing. Raise one arm and palpate breast firmly stand in front of a mirror with sides while seated, lean forward allowing breast hang freely 0 20. Which information will the nurse include when teaching a patient with asthma about the prescribed medication? Utilize the in healed corticosteroid when shortness of breath Occurs inhale slowly and deeply when using the dry powder inhaler hold your breath for five seconds after using the bronchodilator tremor are expected side effects of rapidly acting bronchodilator

Answer 1

16. The correct action to be taken is to report the UAP to the nursing supervisor ,so the correct option is d) .

17. The correct option is d ) The sample should be transported on ice to the laboratory, separated within 15 minutes of collection and analysed immediately. These precautions are necessary as the [ammonia] of standing blood increases spontaneously, due to generation and release of ammonia from red blood cells and, to a lesser extent, the deamination of amino acids by enzymes in the circulation, such as γ‐glutamyltransferase.

18. The correct option is b) . Insert the suction tube just to the end of the ET tube because it will prevent vagal stimulation and hence raising of ICP

19. The correct options are b), c), d) ,and e)