Nokea
A client is receiving oxygen per nasal cannula at 3 L/minute. Which of the following is the approximate inspired oxygen concentration (FiO2)?
- A. 60%
- B. 50%
- C. 40-42%
- D. 28-32%
Correct Answer: D
Rationale: Nasal cannula at 3 L/min delivers approximately 28-32% FiO2 (D), as each liter adds about 4% above room air (21%).
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The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with earphones.
- C. Instruct the client to ignore the voices completely.
- D. Ask the client to describe the voices in detail.
Correct Answer: B
Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations
Which of the following statements regarding proper use of a cane is correct?
- A. When standing, the cane should reach a height even with the natural waist.
- B. When walking downstairs, the cane should be placed down on the step first, followed by the injured leg, and then the good leg.
- C. The elbow should be straight when holding the cane.
- D. The cane should be held in the hand of the same side that needs support.
Correct Answer: B
Rationale: Downstairs, the cane and injured leg move first, followed by the good leg, ensuring stability. The cane is held opposite the injured side, with the elbow slightly bent, and reaches hip level.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
A student nurse overhears her instructor using the term pink puffer. The student knows this term refers to a client with which condition?
- A. chronic bronchitis
- B. chronic obstructive pulmonary disease (COPD)
- C. emphysema
- D. allergic asthma
Correct Answer: C
Rationale: Pink puffer' describes emphysema patients, who maintain oxygenation (pink) but hyperventilate (puffer) due to alveolar destruction.