Answer to Question 1
D
Feedback:
Following administration of an NMJ blocker, the patient will be unable to breathe independently so maintaining an airway and breathing for the patient using a bag-valve mask is the nurse's number-one priority. The patient will not be repositioned until after the artificial airway is placed (endotracheal tube or tracheostomy). Monitoring oxygen saturation and pulse will be second in priority after providing breathing for the patient. The patient will have no independent respirations until the NMJ is metabolized.
Answer to Question 2
B
Feedback:
Because this is the first time the patient has taken penicillin, she is likely to have limited knowledge about the drug. She may not understand the importance of taking the medication as ordered to increase effectiveness of the drug or to report adverse effects. because the patient has not started the drug yet, there is no way to know what adverse effects, if any, she will experience. Only if she develops acute pain related to GI effects of the drug would this be appropriate. If GI symptoms develop it may lead to imbalanced nutrition, but that remains to be seen. No indication about constipation exists.
The nurse is using Standard Precautions to draw blood.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
A nurse administers an intermittent bolus feeding.
A nurse communicates with her non–English-speaking patient through an interpreter
Entry level nurse competencies
Nurse using a stethoscope