Nokea
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
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Which of the following statement is TRUE about do-not-resuscitate (DNR) orders?
- A. Stops all treatment
- B. Prevents CPR
- C. Only for emergencies
- D. All of the above
Correct Answer: B
Rationale: DNR prevents CPR (B), per definition specific to resuscitation. Not all treatment (A), not emergency-only (C), not all (D) focused order. B truly defines DNR's scope, like Mr. Gary's potential choice, ensuring no CPR if heart stops, making it correct.
A nurse uses an institution's procedure manual to confirm how to insert a nasogastric tube. The level of critical thinking the nurse is using is:
- A. Basic critical thinking
- B. Commitment
- C. Complex critical thinking
- D. Scientific method
Correct Answer: A
Rationale: Basic critical thinking involves following established guidelines or procedures, like using a manual for nasogastric tube insertion, typical for novices relying on concrete rules. The nurse here seeks confirmation, indicating dependence on external standards rather than independent judgment. Commitment reflects decisive action based on internalized reasoning, not manual reliance. Complex critical thinking analyzes and adapts procedures (e.g., modifying technique for patient anatomy), requiring experience beyond rote steps. The scientific method tests hypotheses, not applicable to routine protocol checks. Basic critical thinking suits this scenario, as the nurse applies learned steps without deviation, a foundational level ensuring safe practice while building toward higher-order skills in dynamic clinical settings.
Mr. Gary died yesterday, His wife is not talking to anyone and prefers to be alone staring blankly at her husband's picture. This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: D
Rationale: Not talking, staring blankly post-death is depression (D), per Kubler-Ross withdrawal, sadness dominate. Denial (A) disputes, anger (B) lashes, bargaining (C) negotiates all absent. Depression fits her isolation, making it correct.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.
While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
- A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
- B. Find a blank space in your earlier charting, and chart the procedure in that space.
- C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
- D. Chart the current date and time and 'Late entry,' indicating when and what was done.
Correct Answer: D
Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.