Nokea
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?
- A. Drowsiness
- B. Complaint of nausea
- C. Pulse rate of 82
- D. Restlessness
Correct Answer: D
Rationale: Restlessness. Restlessness, increased heart and respiratory rates, and noisy expiration suggest hypoxia and are indications for suctioning.
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The nurse is preparing to care for the client with Ebola, a febrile, hemorrhagic disease. After selecting a disposable surgical hood that extends to the shoulders, what additional PPE should the nurse obtain? Select all that apply.
- A. Docimeter
- B. Disposable N95 respirator
- C. Disposable full face shield
- D. Cloth gown that cannot be reused
- E. Two pair nitrile examination gloves
- F. Boot covers extending to mid-calf
Correct Answer: B,C,E,F
Rationale: B: N95 respirator protects against possible airborne transmission. C: Face shield prevents mucosal exposure. E: Double gloves enhance protection. F: Boot covers prevent lower leg exposure. A: Docimeters are for radiation. D: Cloth gowns are inadequate; impermeable gowns are needed.
Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours since the preparation and the test is tiring
- C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure the urine output for the next day and immediately notify the health care provider if it should decrease
Correct Answer: D
Rationale: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
The nurse learns that the hospitalized client has a history of chronic hepatitis C. Which precaution should the nurse plan to implement?
- A. Airborne
- B. Contact
- C. Droplet
- D. Standard
Correct Answer: D
Rationale: D: Standard precautions are sufficient for hepatitis C, which is transmitted via blood and body fluids. A, B, C are unnecessary as hepatitis C is not airborne or droplet-transmitted.
The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
- A. lower extremity pitting edema
- B. rales
- C. jugular vein distension
- D. weakness in left arm
Correct Answer: D
Rationale: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies.