Nokea
A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action?
- A. Auscultate the child's lung fields
- B. Have the child take slow, deep breaths
- C. Increase the oxygen flow rate to 3 L/min
- D. Verify the position and integrity of the finger probe
Correct Answer: D
Rationale: An inaccurate pulse oximeter reading may result from a poorly positioned probe. Verifying the probe's position is the initial action. Auscultation , deep breaths , or increasing oxygen are secondary without confirming the reading.
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A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?
- A. An Hgb level decrease from 8.9 to 8.7
- B. A temperature reading of 99.4
- C. A white blood cell count of 11,000
- D. A decrease in oozing of blood from the IV site
Correct Answer: D
Rationale: Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets, so they are incorrect.
The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?
- A. 1-month-old infant born at term gestation who exclusively breastfeeds
- B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula
- C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk
- D. 4-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal
Correct Answer: C
Rationale: A preterm infant bottle-fed with breastmilk is most at risk for anemia due to preterm infants' lower iron stores and breastmilk's low iron content. Term breastfed infants (A, D) have adequate stores initially, and iron-fortified formula prevents anemia.