Nokea
A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
- A. Initiate gastric lavage.
- B. Maintain body temperature.
- C. Administer 100% oxygen by mask.
- D. Obtain a psychiatric referral.
Correct Answer: C
Rationale: Administering 100% oxygen displaces carbon monoxide from hemoglobin, the priority in poisoning. Gastric lavage, temperature maintenance, and psychiatric referrals are secondary.
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The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.
The client who does not respond adequately to fluid replacement has an order for an I.V. infusion of dopamine hydrochloride at 5 µg/kg/minute. To determine that the drug is having the desired effect, the nurse should assess the client for:
- A. Increased renal and mesenteric blood flow.
- B. Increased cardiac output.
- C. Vasoconstriction.
- D. Reduced preload and afterload.
Correct Answer: B
Rationale: Dopamine at 5 µg/kg/minute primarily increases cardiac output by enhancing myocardial contractility and heart rate, improving perfusion in shock. Renal/mesenteric flow occurs at lower doses, vasoconstriction at higher doses, and preload/afterload reduction is not a primary effect.
Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply.
- A. Epinephrine
- B. Acetaminophen
- C. Diphenhydramine
- D. Hydrocortisone
- E. Pantoprazole
Correct Answer: A,C,D
Rationale: Epinephrine treats severe allergic reactions (anaphylaxis), diphenhydramine manages mild to moderate allergic symptoms, and hydrocortisone reduces inflammation in allergic reactions. Acetaminophen is for fever or pain, and pantoprazole is for gastric issues, not allergic reactions.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
- A. Peritonitis.
- B. Thrombophlebitis.
- C. Ingestes.
- D. Inguinal hernia.
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.