Nokea
A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
You may also like to solve these questions
A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to this client?
- A. Assess the apical pulse, counting for a full 60 seconds
- B. Take a radial pulse, counting for a full 60 seconds
- C. Use the pulse reading from the electronic blood pressure device
- D. Check for a pulse deficit
Correct Answer: A
Rationale: Assess the apical pulse, counting for a full 60 seconds. It is the nurse’s responsibility to take the client’s pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administering an initial dose of digoxin.
A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
- A. What are you taking for pain and does it provide total relief?'
- B. Did your provider recommend that you be tested for Chlamydia?'
- C. Do you have any questions about your care?'
- D. Did you know a consequence of epididymitis is infertility?'
Correct Answer: B
Rationale: Did your provider recommend that you be tested for Chlamydia?' Epididymitis can result from Chlamydia infection, in which case the client's sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the client's referral is the most important to start with.
The client is admitted with a tentative diagnosis of hepatitis. The nurse determines that which client statement would be consistent with hepatitis?
- A. "I've not been sleeping well; I've heartburn at night that wakes me."
- B. "Whenever I eat dairy products I have diarrhea for a few days."
- C. "Lately I've been short of breath when walking short distances."
- D. "I am a smoker, but lately I can't tolerate the taste of cigarettes."
Correct Answer: D
Rationale: D: Distaste for cigarettes reflects anorexia, a common hepatitis symptom. A: Heartburn suggests GERD. B: Diarrhea with dairy indicates lactose intolerance. C: Shortness of breath is unrelated to hepatitis.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and bedding in hot water
- D. Application of pediculicides
Correct Answer: D
Rationale: Application of pediculicides. Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.