Nokea
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
- A. Adjust the room temperature
- B. Give a bolus of IV fluids
- C. Start O2
- D. Administer meperidine (Demerol) 75 mg IV push
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
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The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound
- B. Cover the exposed viscera with a sterile saline gauze
- C. Gently replace the abdominal contents
- D. Cover the area with a petroleum gauze
Correct Answer: B
Rationale: Covering exposed viscera with sterile saline gauze keeps the tissue moist and prevents infection until surgical intervention, as replacing contents or using non-sterile dressings risks contamination.
The nurse is preparing to hang a unit of blood on a client. The blood has been checked off with two RNs and the pre-infusion vitals recorded. The nurse is at the bedside monitoring the infusion. Shortly after beginning the infusion, the pump alarm sounds. The IV has infiltrated. No blood has yet reached the client. The client is a hard stick, and the nurse realizes that a line cannot be placed within the time frame to begin the infusion. Which action by the nurse is correct?
- A. return the blood and the tubing to the blood bank for storage until an IV can be placed
- B. place the blood bag and tubing in the medication refrigerator until an IV can be restarted
- C. cancel the order for blood and notify the health care provider that the client has no access
- D. wait until 30 minutes has passed while IV placement is attempted, and then waste the blood and chart it as expired
- E. return the blood to the blood bank and notify the next shift when they arrive that they need to start an IV and administer the blood
Correct Answer: C
Rationale: Since no blood reached the client and IV access cannot be re-established within the time frame, the nurse should cancel the order and notify the provider to reassess the need for transfusion.
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST is less specific for myocardial infarction than troponin, CK-MB, or myoglobin.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
- A. A diabetic with a foot ulcer
- B. A client with a deep vein thrombosis receiving intravenous heparin
- C. A client being weaned from a tracheostomy
- D. A post-operative cholecystectomy with a T-tube
Correct Answer: A
Rationale: LPNs can manage stable clients with routine care, like a diabetic with a foot ulcer requiring dressings. Heparin, tracheostomy weaning, and T-tube management involve complex assessments better suited for RNs.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- A. Administer oxygen via nasal cannula
- B. Have narcan (naloxane) available
- C. Prepare to administer blood products
- D. Prepare to do cardioresuscitation
Correct Answer: B
Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.