Nokea
A client is receiving oxygen therapy at 3 L/min per nasal cannula. Which of the following fraction of inspired oxygen (FiO2) measurements does the nurse expect that the client is receiving?
- A. 24%.
- B. 60%.
- C. 32%.
- D. 100%.
Correct Answer: C
Rationale: Nasal cannula at 3 L/min delivers approximately 32% FiO2 (C), as each liter increases FiO2 by about 4% above room air (21%). Other percentages (A, B, D) do not correspond to this flow rate.
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The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: D
Rationale: Malpractice involves professional negligence causing harm, as in administering an incorrect dose of medication.
The nurse is aware that a common mode of transmission of clostridium difficile is:
- A. Use of unsterile surgical equipment
- B. Contamination with sputum
- C. Through the urinary catheter
- D. Contamination with stool
Correct Answer: D
Rationale: C. difficile is transmitted via fecal-oral route through contaminated stool.
Which breakfast selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. Scrambled eggs, toast, and coffee
- B. Bran muffin with margarine
- C. Granola bar and half of a grapefruit
- D. Bagel with jam and skim milk
Correct Answer: D
Rationale: Skim milk is high in calcium, essential for bone health in osteoporosis. The other options lack significant calcium sources, making them less appropriate.
A nurse notes that clients of one surgeon have developed at least twice as many infections as clients of other surgeons on the unit. Which of the following is the most appropriate action?
- A. Report the physician to the hospital administration.
- B. Ask the physician why his rate of infections is so high.
- C. Report the observations to the infection control nurse.
- D. Say nothing as infection rates vary from time to time.
Correct Answer: C
Rationale: Reporting to the infection control nurse (C) initiates investigation and intervention. Reporting to administration (A) or confronting the physician (B) is premature, and ignoring the issue (D) is unsafe.