Nokea
A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min per nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?
- A. COPD clients are stimulated to breathe by hypoxia.
- B. COPD clients depend on a low carbon dioxide level.
- C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen.
- D. COPD clients thrive on a high oxygen level.
Correct Answer: A
Rationale: COPD clients are compensating for low oxygen and high carbon dioxide levels. Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia. Increasing the level of oxygen decreases the stimulus to breathe.
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The client is prescribed varenicline for smoking cessation. The nurse concludes that varenicline is being prescribed primarily for its antagonistic effect. Which statement describes this effect?
- A. Gets readily absorbed into the bloodstream for rapid effectiveness
- B. Demonstrates a high degree of attractiveness for a specific receptor
- C. Blocks receptors in the brain that produce the pleasurable effects of smoking
- D. Stimulates receptors stimulated by smoking, producing similar pleasurable effects.
Correct Answer: C
Rationale: Varenicline (Chantix) functions as an antagonist, blocking receptors to reduce the pleasurable effects of smoking.
The HCP orders a digitalizing dose of digoxin 225 mcg IV now to be given to a 3-year-old. The pharmacy sends a solution of 500 mcg in 50 mL of D5W. How many mL should the nurse administer?
Correct Answer: 22.5
Rationale: Use a proportion formula: 500 mcg : 50 mL :: 225 mcg : X mL; 500X = 11250; X = 22.5 mL.
For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis.
The nurse is developing a teaching plan for the client prescribed nortriptyline. Which self-care aspects should be included to minimize medication side effects and prevent injury? Select all that apply.
- A. Avoid eating processed meats, cheeses, and wines.
- B. Suck on candy or ice chips to keep your mouth moist.
- C. Run water in the bathroom to stimulate urination if needed.
- D. Increase fluid and fiber in the diet to prevent constipation.
- E. Avoid driving until vision is completely clear to prevent injury.
- F. Increase exposure to sunlight to facilitate vitamin D absorption.
Correct Answer: B,C,D,E
Rationale: Nortriptyline (Pamelor) causes dry mouth, urinary retention, constipation, and blurred vision. Sucking on candy, running water to stimulate urination, increasing fluid and fiber, and avoiding driving until vision is clear are appropriate.
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing is the property of another and must be treated with care.
- B. Such care facilitates repair and salvage of the clothing.
- C. The clothing of a trauma victim is potential evidence with legal implications.
- D. Such care decreases trauma to the family members receiving the clothing.
Correct Answer: C
Rationale: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.