Nokea
A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?
- A. Bradycardia
- B. Bradypnea
- C. Lethargy
- D. Intercostal retractions
Correct Answer: D
Rationale: The correct answer is D: Intercostal retractions. In postoperative atelectasis, there is a collapse of lung tissue leading to decreased oxygen exchange and hypoxia. Intercostal retractions indicate increased work of breathing as the body tries to compensate for the decreased lung function. Bradycardia and bradypnea are not typically associated with hypoxia but rather with decreased oxygen delivery to tissues. Lethargy is a nonspecific symptom and may not directly correlate with hypoxia in this scenario.
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When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do. What action should be taken by the nurse? What criterion of informed consent has not been met in this situation?
- A. Inform the surgeon immediately.
- B. Document the patient's statement.
- C. Administer the medication as ordered.
- D. Delay medication until the surgeon clarifies.
Correct Answer: A
Rationale: Informed consent requires that the patient understands the procedure, which hasn't been met here.
A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?
- A. Carbon monoxide poisoning
- B. Heat stroke
- C. Hypersensitivity reaction
- D. Oxygen toxicity
Correct Answer: A
Rationale: The correct answer is A: Carbon monoxide poisoning. When the furnace is turned on for the first time, it may release carbon monoxide, a colorless and odorless gas that can cause headaches and vertigo. Carbon monoxide binds to hemoglobin, reducing oxygen delivery to tissues, leading to symptoms. Heat stroke (B) is caused by prolonged exposure to high temperatures. Hypersensitivity reactions (C) involve the immune system's response to an allergen. Oxygen toxicity (D) occurs with prolonged exposure to high levels of oxygen.
Identify the five rights of delegating nursing care (select all that apply).
- A. Right time
- B. Right task
- C. Right patient
- D. Right person
Correct Answer: B
Rationale: Effective delegation involves the right task, patient, person, circumstance, and supervision/evaluation.
Jill Means, 36, has had a vaginal radium implant placed as one of the treatments for her cervical cancer. She calls to tell you that during a coughing spell it has 'been pushed out'. You should:
- A. place signs on the door stating radioactivity danger.
- B. have Jill reinsert the applicator like a tampon.
- C. call the physician and apprise him of the situation.
- D. use forceps to place the applicator in the receptacle.
Correct Answer: D
Rationale: Signs should be placed on the door after the implant has been done, and not just when the implant is dislodged. By picking the applicator up, Jill would experience burns on her fingers/hands that would be avoidable, so need to teach her not to do so. The applicator has been contaminated, it would not be replaced in any case. Calling the physician and apprising him would certainly be necessary, but would be done after the applicator has been taken care of. Lead containers should be available to place the applicator in, and forceps would be used to do so to protect from radiation burns.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway.
- B. Call for help.
- C. Establish that the client is unresponsive.
- D. See if anyone saw the client fall.
Correct Answer: C
Rationale: Checking responsiveness is the first step in assessing the situation.