Nokea
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
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A client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?
- A. Check the client's blood glucose
- B. Check the client's vital signs
- C. Report the findings to the health care provider
- D. Slow down the rate of infusion
Correct Answer: A
Rationale: Nausea, abdominal pain, and thirst in a TPN client suggest hyperglycemia, so checking blood glucose is the best action. Vital signs , reporting , or slowing infusion are secondary without glucose confirmation.
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.
Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.
- A. Client with asthma exacerbation and blood pressure is 150/90 mm Hg
- B. Client with spinal cord injury and blood pressure is 50/60 mm Hg
- C. Client with coronary artery disease on metoprolol, pulse is 62/min
- D. Elderly client with black stool; pulse is 112/min
- E. Neonate crying inconsolably at feeding time; pulse is 160/min
Correct Answer: B,D,E
Rationale: Concerning conditions include: spinal cord injury with hypotension suggesting neurogenic shock; black stool and tachycardia indicating possible GI bleeding; and inconsolable neonate with tachycardia suggesting distress. Asthma with hypertension and stable pulse on metoprolol are less urgent.
Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
- A. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
- B. Child with an abscess on the buttock that is red, swollen, and warm to the touch
- C. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
- D. Child with low-grade fever, barking cough, and runny nose who has mild retractions
Correct Answer: A
Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.
The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?
- A. WBC 7500
- B. Serum glucose 92
- C. Protein 3.5
- D. Serum Creatinine 2.0
Correct Answer: D
Rationale: Garamycin (gentamicin) is an aminoglycoside antibiotic that can cause nephrotoxicity. A serum creatinine level of 2.0 mg/dL is elevated (normal range is approximately 0.6-1.2 mg/dL), indicating potential kidney damage, an adverse reaction. Answers A, B, and C represent normal or unrelated lab values.