Nokea
A client with chronic obstructive pulmonary disease is receiving $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$ via nasal cannula. He is anxious and short of breath, and his mental status is clouded. The nurse should:
- A. Increase the $\mathrm{O}_2$ to $6 \mathrm{~L}/\mathrm{min}$.
- B. Monitor for signs of impending respiratory failure.
- C. Maintain the $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$, but increase the humidity.
- D. Check the vital signs and oxygen saturation level.
Correct Answer: D
Rationale: Checking vital signs and oxygen saturation assesses the cause of symptoms (e.g., hypoxia, hypercapnia). Increasing O2 risks CO2 retention in COPD. Monitoring is passive. Humidity is secondary.
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A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
- A. It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart.'
- B. It is my responsibility to witness the signature of the patient before surgery is performed.'
- C. It is my responsibility to explain the surgery and ask the patient to sign the consent form.'
- D. It is my responsibility to answer questions that the patient may have before surgery.'
Correct Answer: C
Rationale: physician should provide explanation and obtain patient's signature
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
A 35-year-old woman one-day postpartum receiving butorphanol tartrate (Stadol) 1 mg IM.
Which of the following actions is MOST important for the nurse to take after administering the medication?
- A. Observe the woman for sedation.
- B. Monitor the vital signs.
- C. Assess for visual disturbances.
- D. Evaluate fluid status.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice and how it relates to Stadol. (1) causes sedation, but not most important (2) correct-decreases rate and depth of respirations (3) diplopia and blurred vision are side effects, but not most important (4) not side effect of medication
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
- A. I am taking less insulin now than I did two months ago.
- B. I am eating a large bedtime snack.
- C. I walk 15 minutes after lunch every day.
- D. I check my blood sugar two hours after each meal.
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.