Nokea
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.
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The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
Correct Answer: E,D,C,B,A
Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
- A. Diet pattern
- B. Mobility
- C. Fluid intake
- D. Sexual function
Correct Answer: D
Rationale: Sexual function is not directly related to bowel and bladder retraining, unlike diet, mobility, and fluid intake.
A client with severe anemia is to receive a unit of whole blood. In the event of a transfusion reaction, the first action by the nurse should be to:
- A. Notify the physician and the nursing supervisor
- B. Stop the transfusion and maintain an IV of normal saline
- C. Call the lab for verification of type and cross match
- D. Prepare an injection of Benadryl (diphenhydramine)
Correct Answer: B
Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.
- A. 18%
- B. 23%
- C. 32%
- D. 36%
Correct Answer: B
Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.