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A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
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A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.
A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
Correct Answer: 0.3
Rationale: Correct Answer: 0.3 mL
Rationale:
1. Calculate the total dose needed: 10 mg.
2. Determine the concentration: 40 mg/mL.
3. Use the formula: dose needed / concentration available = volume to administer.
4. Plug in the values: 10 mg / 40 mg/mL = 0.25 mL.
5. Round up to the nearest practical dose increment: 0.3 mL.
Summary:
Choice A (0.5 mL): Incorrect, as it does not accurately calculate the volume needed.
Choices B-G: Irrelevant, as they do not follow the correct calculation method.
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.
- A. Older adults are more prone to dehydration than younger adults.
- B. Older adults need the same amount of most vitamins and minerals as younger adults.
- C. Many older men and women need calcium supplementation.
- D. Older adults need more calories than they did when they were younger.
- E. Older adults should consume a diet low in carbohydrates.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.