Nokea
A nurse receives report about a client who has NS infusing IV at 125 ml/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hr. Which of the following actions should the nurse take first?
- A. Reposition the client
- B. Document the client's IV intake in the medical record.
- C. Request a new IV fluid prescription.
- D. Check the IV tubing for obstruction.
Correct Answer: D
Rationale: Check the IV tubing for obstruction. The nurse should reposition but this isn't the first step, the nurse should document but this too isn't the first step. The nurse should request new IV fluid prescription to compensate for lost fluid but this isn't the first step.
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The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?
- A. Turn the suction level up to $60 \mathrm{~cm}$ prior to inserting the catheter.
- B. Increase the oxygen flow to the client by $20 \%$ prior to suctioning.
- C. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.
- D. Instruct the client to cough forcefully from the abdomen prior to suction.
Correct Answer: C
Rationale: Hyperinflation before suctioning prevents hypoxia by delivering 2-3 breaths at 1.5 times the tidal volume (C) typically via a manual resuscitator or ventilator setting. Adjusting suction level (A) does not address oxygenation. Increasing oxygen flow (B) is insufficient for hyperinflation. Coughing (D) does not ensure adequate oxygenation making C the correct method to maintain oxygen levels during suctioning.
The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Alginate
- B. Gauze
- C. Transparent
- D. Hydrocolloid
Correct Answer: D
Rationale: Hydrocolloid promotes healing in stage 2 by creating a moist wound bed. Alginate dressings are for stage 3 and 4 injuries to absorb drainage, moist gauze is for stage 4 or unstageable dressing that need debridement, transparent dressings are for stage 1 to prevent further friction.
When moving a client up in bed with the assistance of another caregiver, the nurse should:
- A. Elevate the head of the bed
- B. Have the client fold the arms across the chest
- C. Ask another nurse [incomplete]
- D. Maintain a pillow under the client's head
Correct Answer: D
Rationale: A pillow provides comfort and support. Elevating (A) hinders movement. Folding arms (B) isn’t standard. Asking another nurse (C) is unclear.
Which breakfast menu is most appropriate for a patient with diabetes?
- A. Oatmeal with artificial sweetener, whole-grain toast, tea
- B. Two eggs, two strips of bacon, orange juice, coffee
- C. One slice whole-grain toast with peanut butter,
- D. One half grapefruit, cranberry juice, bagel with sugar-free jelly
Correct Answer: A
Rationale: Oatmeal is a good source of fiber, which can help manage blood sugar levels. Whole-grain toast provides complex carbohydrates and fiber, and using an artificial sweetener in oatmeal reduces sugar intake. Tea is a good beverage choice as it does not contain sugar or calories if not sweetened.
A nurse cares for a group of clients who are experiencing symptoms of withdrawal from alcohol. Which finding requires immediate follow-up?
- A. Tremors
- B. Inability to sleep
- C. Hematemesis
- D. Transient hallucinations
Correct Answer: C
Rationale: The client needs to be seen immediately. Hematemesis is a symptom of rupture of associated esophageal varices. The mortality rate with acute bleeding is 10% to 40% and is related to failure to control a bleeding episode.