Nokea
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?
- A. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)
- B. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
- C. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
- D. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)
Correct Answer: A
Rationale: PaO2 < 50 mm Hg and PaCO2 > 50 mm Hg (A) indicate acute respiratory failure, requiring immediate intervention. Other options show less severe hypoxemia or normal values.
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The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.
The nurse is caring for a client with a terminal illness who is expected to die during the shift. The nurse notes that the client has loud, wet respirations. Which of the following medications would effectively treat this finding?
- A. IM lorazepam
- B. sublingual atropine
- C. transdermal fentanyl
- D. sublingual ondansetron
Correct Answer: B
Rationale: Sublingual atropine (B) reduces salivary secretions, alleviating 'death rattle.' Lorazepam (A) is for anxiety, fentanyl (C) for pain, and ondansetron (D) for nausea.