A nurse is caring for a group of patients. Which patient should the nurse see first?
A patient with hypercapnia wearing an oxygen mask
A patient with a chest tube ambulating with the chest tube unclamped
A patient with thick secretions being tracheal suctioned first and then orally
A patient with a new tracheostomy and tracheostomy obturator at bedside
The Correct Answer is B
A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.
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Correct Answer is D
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.
Correct Answer is A
Explanation
A. The tuberculin test is administered intradermally, and the needle should be inserted at a 15-degree angle to ensure the medication is delivered just under the surface of the skin.
B. A 90-degree angle is used for intramuscular injections, not for intradermal tests like the tuberculin test.
C. A 30-degree angle is commonly used for subcutaneous injections and is too deep for an intradermal injection.
D. A 45-degree angle is also used for subcutaneous injections but is not suitable for intradermal injections.