Nokea
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
- A. External light sources may cause falsely high oximetry values
- B. A bright light in the client's face may cause a low pulse oximetry
- C. External light sources may cause falsely low oximetry values
- D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Correct Answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
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The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
- A. I need to change positions slowly.
- B. I need to monitor my blood pressure every week.
- C. I need to use salt moderately in cooking and on foods.
- D. I need to report signs and symptoms of infection to my doctor.
Correct Answer: D
Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Client education includes changing positions slowly to avoid orthostatic hypotension, monitoring blood pressure regularly, and using salt moderately as part of a heart-healthy diet. However, reporting signs and symptoms of infection is not directly related to benazepril use, as infections are not a common side effect. The client may need further teaching to clarify the specific side effects to monitor, such as cough, swelling, or signs of hyperkalemia.
Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct Answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
- A. Inhales slowly
- B. Breathes through the nose
- C. Removes the mouthpiece to exhale
- D. Forms a tight seal around the mouthpiece with the lips
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication?
- A. This medication can cause severe drowsiness.
- B. The client must avoid foods that contain tyramine.
- C. The medication is associated with a high rate of abuse.
- D. The medication will begin to alleviate symptoms of depression almost immediately.
Correct Answer: B
Rationale: MAOIs are used to treat depression. Although MAOIs usually produce hypotension as a side effect, potentially lethal hypertension can occur if the client eats foods that contain tyramine. Such foods include aged cheeses, hot dogs, and beer, among others. The medication does not cause drowsiness, is not associated with a high rate of abuse, and does not act almost immediately.
A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
- A. Delirium
- B. Muscle rigidity
- C. Hypotension
- D. Pinpoint rash
Correct Answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.