Nokea
The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.
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The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter?
- A. Have the client wear a mask
- B. Have the client wear gloves
- C. Wear a mask
- D. Wear an isolation gown
Correct Answer: A
Rationale: Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room.
A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63 mmHg, HCO3 23, and oxygenation saturation (SaO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?
- A. tuberculosis (TB)
- B. pneumonia
- C. pleural effusion
- D. hypoxia
Correct Answer: D
Rationale: Low PO2 (63 mmHg) and SaO2 (93%) indicate hypoxia, despite normal pH, PCO2, and HCO3. TB, pneumonia, or pleural effusion may cause hypoxia but are not the direct etiology shown by ABGs. Physiological Adaptation
Which of the following interventions is most helpful in determining the need for oxygen therapy for a client with COPD?
- A. Asking the client whether he needs $\mathrm{O}_2$
- B. Assessing the client's level of fatigue
- C. Evaluating the hemoglobin level
- D. Using a pulse oximeter on the client's ear lobe
Correct Answer: D
Rationale: Pulse oximetry objectively measures oxygen saturation, guiding the need for oxygen therapy in COPD. Subjective reports and hemoglobin levels are less direct.
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
- A. Central nervous system damage
- B. Moderate anemia
- C. Renal tubule damage
- D. Growth impairment
Correct Answer: A
Rationale: Central nervous system damage. The most serious consequences of chronic lead poisoning occur in the central nervous system, leading to intellectual deficits or even death.
A client recovering from a head injury is receiving medication and nutritional feedings by nasogastric tube. The doctor has ordered medication to prevent seizure activity. The medication is supplied by the pharmacy in tablet form. Before administering the medication, the nurse should:
- A. Crush the medication and envelop it in a small amount of ice cream before giving.
- B. Help the client to sit upright while giving the tablet by mouth.
- C. Crush the tablet, mix in 100 ccs of tube feeding, and administer via NG tube.
- D. Ask the pharmacist if the medication is available in liquid form.
Correct Answer: D
Rationale: For NG tube administration, liquid medication is preferred to ensure proper delivery and absorption. Crushing tablets may alter efficacy, and oral administration is inappropriate.