Nokea
A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?
- A. Send an oxygen tank from the facility home with the client
- B. Instruct the client's family to contact the insurance provider about the oxygen equipment
- C. Contact social services about the delivery of the oxygen equipment
- D. Notify the provider about the delayed oxygen tank delivery
Correct Answer: C
Rationale: The correct action for the nurse to take is to contact social services about the delivery of the oxygen equipment. This ensures that the necessary equipment is delivered to the client's home promptly. Choice A is incorrect because sending an oxygen tank from the facility is not a sustainable solution and may lead to legal and safety issues. Choice B is incorrect as contacting the insurance provider is not the appropriate course of action to address the delayed delivery. Choice D is also incorrect because notifying the provider about the delay may not directly lead to the timely delivery of the oxygen equipment.
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Which atrioventricular heart block is also referred to as Mobitz II?
- A. Third-degree atrioventricular heart block
- B. Second-degree atrioventricular heart block
- C. First-degree atrioventricular heart block
- D. Complete heart block
Correct Answer: B
Rationale: The correct answer is B. Second-degree atrioventricular heart block is also known as Mobitz II. In Mobitz II, some atrial impulses are blocked from reaching the ventricles, resulting in occasional dropped beats. Third-degree atrioventricular heart block is known as complete heart block, where no atrial impulses reach the ventricles. First-degree atrioventricular heart block is a condition where there is delayed conduction between the atria and ventricles but all atrial impulses are eventually conducted to the ventricles.
A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct Answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
What percentage of term newborns have a congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion?
- A. 2% to 4%
- B. 10% to 20%
- C. 5% to 10%
- D. 7% to 9%
Correct Answer: A
Rationale: The correct answer is A: 2% to 4%. According to research, 2% to 4% of term newborns have congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion. Choices B, C, and D provide percentages that are higher than the actual prevalence of congenital heart disease in newborns caused by environmental factors, making them incorrect.
A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
- A. Apply vest restraints to residents who are confused
- B. Keep all four side rails up on beds at night
- C. Accompany residents over 85 years of age during ambulation
- D. Implement rounds every 2 hours during the day to offer toileting
Correct Answer: D
Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.
Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?
- A. The client will be very thirsty.
- B. The client will complain of nausea.
- C. The client will need to urinate.
- D. The client will have moist skin.
Correct Answer: D
Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.