Nokea
A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
- A. 5%
- B. 10%
- C. 15%
- D. 25%
Correct Answer: A
Rationale: Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%. Normal carboxyhemoglobin (HbCO) levels are 0% to 3% for nonsmokers and 3% to 8% for smokers. Levels of 10% to 20% cause headaches, nausea, vomiting, and dyspnea. Levels of 30% to 40% cause severe headaches, syncope, and tachydysrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Options 2, 3, and 4 are elevated levels.
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A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding should the nurse expect to note as a result of this condition?
- A. Dehydration
- B. Overhydration
- C. A high hematocrit level
- D. A low hemoglobin level
Correct Answer: D
Rationale: Pathological anemia of pregnancy is primarily caused by iron deficiency. When the hemoglobin level is below 11 mg/dL (110 mmol/L), iron deficiency is suspected. An indirect index of the oxygen-carrying capacity is determined via a packed red blood cell volume or hematocrit level. Dehydration and overhydration are not specifically associated with iron deficiency anemia.
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.
When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client's safety?
- A. Monitor the client's urinary output.
- B. Assess the client for neurological problems.
- C. Ensure that the bed rails remain in the up position.
- D. Monitor the client's vital signs and electrocardiogram (ECG) frequently.
Correct Answer: D
Rationale: Flecainide is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. However, the nurse must monitor for the development of a new or worsening dysrhythmia. Options 1, 2, and 3 are components of standard care but are not specific to this medication.
A client scheduled for pneumonectomy tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?
- A. They are generally removed after 36 to 48 hours.
- B. Not every lung surgery requires chest tubes to be used.
- C. They usually remain in place for a full week after surgery.
- D. Your type of surgery rarely requires chest tubes to be inserted after surgery.
Correct Answer: D
Rationale: Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies.
The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) should plan care by implementing which intervention?
- A. Beginning thrombolytic therapy
- B. Placing the client on continuous cardiac monitoring
- C. Infusing intravenous (IV) fluid at a rate of 150 mL per hour
- D. Administering oxygen at a rate of 6 L per minute by nasal cannula
Correct Answer: B
Rationale: Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the primary health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure that there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 L per minute unless otherwise prescribed.