Nokea
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.
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The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?
- A. Administer morphine to the client.
- B. Verify when the client had the last flatus or bowel movement.
- C. Administer oxybutynin to the client.
- D. Verify the amount and characteristics of the client's urine output.
Correct Answer: D
Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.
The nurse is to administer an iron injection to an adult. How should this be administered?
- A. Subcutaneous in the arm
- B. Intradermal in the forearm
- C. Intramuscular in the deltoid
- D. Z track intramuscular in the gluteal
Correct Answer: D
Rationale: Iron injections are given via Z-track intramuscular in the gluteal muscle to prevent leakage and skin staining, ensuring deep muscle administration.
The most common complication following a myocardial infarction is:
- A. Hyperkalemia
- B. Cardiac dysrhythmia
- C. Acute respiratory distress
- D. Hypovolemic shock
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-myocardial infarction due to ischemic changes affecting the heart's electrical conduction.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.