Nokea
A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
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A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.
A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct Answer: A
Rationale: Respiratory acidosis is characterized by an increase in carbon dioxide levels in the blood, leading to acidosis. This condition can affect the heart's electrical conduction system, resulting in widened QRS complexes on an electrocardiogram (ECG). Hyperactive deep tendon reflexes, bounding peripheral pulses, and warm, flushed skin are not typically associated with respiratory acidosis.
A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Assist the client to breathe into a paper bag.
- C. Have the client tuck her chin to her chest.
- D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Correct Answer: A
Rationale: The client is exhibiting signs of hyperventilation, which can occur as a result of rapid breathing techniques such as pattern-paced breathing during labor. Administering oxygen via nasal cannula can help the client rebalance her oxygen and carbon dioxide levels, which will alleviate the lightheadedness and tingling sensations she is experiencing. Oxygen therapy is the appropriate intervention for respiratory alkalosis caused by hyperventilation. Assisting the client to breathe into a paper bag or instructing her to increase her respiratory rate would exacerbate the hyperventilation and should be avoided. Tucking her chin to her chest is not an appropriate intervention in this situation.