Nokea
A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?
- A. A PO2 of 88
- B. Rales on auscultation
- C. Blood pressure decrease to 90/48 from 120/70
- D. A decrease in spontaneous respirations
Correct Answer: C
Rationale: PEEP can increase intrathoracic pressure, reducing venous return and causing hypotension (e.g., BP drop to 90/48), an undesirable effect requiring intervention.
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A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
- A. Fraud
- B. Malpractice
- C. Negligence
- D. Tort
Correct Answer: A
Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.
Which of the following roommates would be most suitable for the client with myasthenia gravis?
- A. A client with hypothyroidism
- B. A client with Crohn's disease
- C. A client with pylonephritis
- D. A client with bronchitis
Correct Answer: A
Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.
A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
- A. Frequent dental visits
- B. Frequent lab work
- C. Additional fluids
- D. Additional sodium
Correct Answer: B
Rationale: Depakote requires regular lab monitoring (e.g., liver function, platelet counts) to detect potential side effects like hepatotoxicity or thrombocytopenia.
The infant is admitted to the unit with Tetralogy of Fallot. The nurse would anticipate an order for which medication?
- A. Digoxin
- B. Epinephrine
- C. Aminophyline
- D. Atropine
Correct Answer: A
Rationale: Digoxin is commonly used in Tetralogy of Fallot to improve cardiac function and manage heart failure symptoms.