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A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
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A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?
- A. bleeding time
- B. platelet count
- C. activated PTT
- D. clotting time
Correct Answer: C
Rationale: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
The nurse sees multiple items on the client's bedside table. Which items should the nurse remove because they pose a risk of infection for the client? Select all that apply.
- A. The menu from the client's last meal
- B. A glass of water without a cover
- C. An empty urinal that had been rinsed
- D. A sealed package of soda crackers
- E. A pitcher of water covered with a lid
- F. A bloody alcohol swab from an injection
Correct Answer: B,C,F
Rationale: B: Uncovered water can become contaminated over time. C: A rinsed urinal may still harbor microorganisms. F: A bloody swab is a biohazard and can transmit pathogens. A, D, E are safe as they are either non-contaminable or properly sealed.
Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct Answer: B
Rationale: Sudden cessation of any medication, unless medically necessary, is ill-advised.
A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to this client?
- A. Assess the apical pulse, counting for a full 60 seconds
- B. Take a radial pulse, counting for a full 60 seconds
- C. Use the pulse reading from the electronic blood pressure device
- D. Check for a pulse deficit
Correct Answer: A
Rationale: Assess the apical pulse, counting for a full 60 seconds. It is the nurse’s responsibility to take the client’s pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administering an initial dose of digoxin.
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
- A. I knew this would happen. I've been eating too much red meat lately.'
- B. I really enjoyed my fishing trip yesterday. I caught two fish.'
- C. I have really been working hard practicing basketball.'
- D. I went to get a cold checked out last week, and I have gotten worse.'
Correct Answer: D
Rationale: I went to get a cold checked out last week, and I have gotten worse.' Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.