Nokea
A client is experiencing episodes of hyperventilation related to the surgery scheduled for tomorrow. The appropriate nursing action to help control hyperventilation is to:
- A. administer Valium 10-15 mg PO q4h and q1h prn.
- B. keep the temperature in the client's room high to reduce respiratory stimulation.
- C. have the client hold their breath or breathe into a paper bag when the hyperventilation episodes occur.
- D. use distractions.
Correct Answer: C
Rationale: An adult Valium dosage for treatment of anxiety is 2-10 mg PO from two to four times daily. As written, the order would place a client at risk for an overdose. A high room temperature could increase the hyperventilating episodes by stimulating the respiratory system. Holding one's breath and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation, which is caused by anxiety or fear.
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What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
- A. Observing for confusion
- B. Auscultating breath sounds
- C. Confirming the gag reflex
- D. Measuring blood pressure
Correct Answer: C
Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.
Which signs and symptoms of lithium toxicity should a nurse monitor for?
- A. Constipation
- B. Vomiting
- C. Amnesia
- D. Muscular rigidity
Correct Answer: B
Rationale: Vomiting is a common early sign of lithium toxicity, indicating the need for immediate medical attention.
Which statement best describes emmetropia?
- A. Difficulty with near vision
- B. Difficulty with far vision
- C. Visual distortion caused by an irregularly shaped cornea
- D. Normal vision
Correct Answer: D
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Nurses who rotate shifts or work nights are at risk for developing shift work sleep disorder characterized by insomnia, sleepiness, and fatigue. Identify at least three negative implications for the nurse.
- A. Increased risk of errors
- B. Decreased job satisfaction
- C. Higher likelihood of accidents
- D. Sleep just before going to work
Correct Answer: A
Rationale: The correct answers are A, B, and C. Shift work sleep disorder increases the risk of errors, reduces job satisfaction, and raises the likelihood of accidents due to impaired alertness.
On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse’s action have on the patient?
- A. Protects the patient from addiction and toxic effects of the drug
- B. Prevents hastening or causing a patient’s death from respiratory dysfunction
- C. Contributes to unnecessary suffering and physical and psychosocial dysfunction
- D. Indicates that the nurse understands the adage of “start low and go slow” in administering analgesics
Correct Answer: C
Rationale: The correct answer is C. Delaying pain relief contributes to unnecessary suffering and can negatively impact recovery.