Nokea
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Notify the physician
- C. Encourage deep breathing exercises
- D. Reposition the client to semi-Fowler's
Correct Answer: B
Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.
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The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
- A. Vertigo.
- B. Tinnitus.
- C. Nausea.
- D. Ataxia.
- E. Hearing loss.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.
The nurse is caring for a client with a venous leg ulcer. Which of the following interventions should be included in the plan of care?
- A. Apply compression bandages.
- B. Keep the leg in a dependent position.
- C. Clean the ulcer with alcohol-based solution.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Compression bandages promote venous return and healing in venous leg ulcers.
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
- A. Your client may be experiencing a fluid overload.
- B. Your client may be experiencing an embolus.
- C. Your client may be hyperglycemic.
- D. Your client may have an inadvertent pneumothorax.
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
- A. Fruity breath odor.
- B. Kussmaul respirations.
- C. Bradycardia.
- D. Polyuria.
- E. Hypotension.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.