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A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
- A. A high concentration of carbon monoxide can cause death.
- B. I should purchase a carbon monoxide detector for my home.
- C. Breathing in carbon monoxide can cause headaches and nausea.
- D. I can detect the presence of carbon monoxide by a metallic odor.
Correct Answer: D
Rationale: The correct answer is D. Carbon monoxide is odorless, colorless, and tasteless, so it cannot be detected by a metallic odor. This is a common misconception that needs to be corrected. A: True, high concentrations can be fatal. B: Correct, a detector is essential for safety. C: True, common symptoms of CO poisoning. In summary, D is incorrect because carbon monoxide does not have a metallic odor, unlike the other options which are all accurate statements regarding carbon monoxide poisoning.
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A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
- A. Place a black tag on the client’s upper body and attempt to help the next client in need.
- B. Reposition the client’s upper airway a second time before assessing his respirations.
- C. Start CPR.
- D. Place a red tag on the client’s upper body and obtain immediate help from other personnel.
Correct Answer: A
Rationale: The correct answer is A: Place a black tag on the client’s upper body and attempt to help the next client in need. In this scenario, the client is apneic despite repositioning the airway and has a weak pulse. The client's condition falls under "expectant" during triage, indicated by a black tag. The nurse should prioritize helping those who have a higher chance of survival first. Placing a black tag and moving on to assist others is essential to maximize the number of lives saved in a mass casualty event. Starting CPR (choice C) may be futile if the client is trapped under a car with severe injuries. Choice B, repositioning the airway again, is unlikely to change the client's apneic status. Choice D, placing a red tag, is incorrect as this tag is typically used for immediate care cases.
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
- A. Administer 50,000 units of heparin by IV bolus every 12 hours.
- B. Have vitamin K available on the nursing unit.
- C. Use tubing specific for heparin sodium when administering the infusion.
- D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
Correct Answer: D
Rationale: The correct answer is D: Check the activated partial thromboplastin time (aPTT) every 6 hours. This is crucial to monitor the therapeutic effect of heparin, ensuring the client's blood does not become too thin or too thick. Regular aPTT monitoring helps adjust the heparin infusion rate to maintain the desired anticoagulant effect.
Explanation of why other choices are incorrect:
A: Administering a large dose of heparin by IV bolus is dangerous and can lead to bleeding complications. Incorrect.
B: Having vitamin K available is not specifically related to managing heparin therapy. Incorrect.
C: Using tubing specific for heparin is important but is not the priority action in this scenario. Incorrect.