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A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: Lower the oxygen rate. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. Unless corrected, it can lead to the client's death.
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Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
The charge nurse is planning hospital bed placements for the five male clients identified in the exhibit. Two double rooms and one private room are available. Which room assignments should be made by the charge nurse?
- A. Client B: private room; clients C and E in same room; clients A and D in same room
- B. Client C: private room; clients A and D in same room; clients B and E in same room
- C. Client E: private room; clients B and C in same room; clients A and D in same room
- D. Client C: private room; clients A and B in same room; clients D and E in same room
Correct Answer: B
Rationale: B: Client C requires airborne precautions and a private room. A and D share the same organism and contact precautions. B and E require standard precautions and can share a room.
The HCP prescribes metronidazole 0.5 g orally three times daily for the client with an infection. The label states that each tablet is 250 mg. How many tablets should the nurse prepare to administer for one dose?
Correct Answer: 2
Rationale: 0.5 g = 500 mg; 500 mg/ 250 mg/tablet = 2 tablets per dose.
The nurse is using chlorhexidine to cleanse a vein site prior to inserting an IV catheter. While pressing the activated applicator on the skin, what should the nurse do next?
- A. Scrub the skin back and forth for 30 seconds.
- B. Scrub the skin in a circular motion for 10 seconds.
- C. Scrub until the solution is visually wet on the vein.
- D. Scrub until the skin appears to be dark brown in color.
Correct Answer: A
Rationale: A: Back-and-forth scrubbing for 30 seconds ensures effective antisepsis. B: Circular motion and 10 seconds are inadequate. C: Visual wetness is insufficient. D: Chlorhexidine is clear, causing no discoloration.