Nokea
A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?
- A. Notify physician.
- B. Administer oxygen.
- C. Assess client and reposition pulse oximeter.
- D. Collect an arterial specimen for ABGs.
Correct Answer: C
Rationale: Assessing and repositioning the pulse oximeter (C) checks for false readings first. Oxygen (B), notifying physician (A), or ABGs (D) follow if needed.
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For which of the following reasons would the nurse use the Braden Scale to assess a client?
- A. To determine if the client is suffering from delirium.
- B. To determine if the client is at risk for developing pressure sores.
- C. To determine if the client is at risk for falls.
- D. To determine if the client is at risk for substance abuse.
Correct Answer: B
Rationale: The Braden Scale assesses risk for pressure sores (B) by evaluating factors like mobility and skin moisture. It is not used for delirium (A), falls (C), or substance abuse (D).
The nurse is preparing to administer insulin to a client with type 1 diabetes mellitus. The client is to receive 10 units of regular insulin and 20 units of NPH insulin. Which of the following actions by the nurse is correct?
- A. Draw up the NPH insulin first, then the regular insulin in the same syringe.
- B. Administer the regular insulin in one syringe and the NPH in another.
- C. Mix the regular insulin with the NPH insulin in a vial before drawing it up.
- D. Administer the regular insulin 30 minutes after the NPH insulin.
Correct Answer: A
Rationale: regular insulin is drawn up first, followed by NPH, to prevent contamination of the regular insulin with NPH
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states,
- A. I will not be able to have wine and aged cheese anymore.'
- B. I should avoid all dairy products from now on.'
- C. Taking this medication with vitamin K-containing foods is dangerous.'
- D. I will need to decrease my dietary fiber now.'
Correct Answer: A
Rationale: MAOIs like phenelzine require avoiding tyramine-rich foods (e.g., wine, aged cheese) to prevent hypertensive crisis. Dairy, vitamin K, and fiber are not contraindicated.
A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
- A. Produces changes in the kidneys
- B. Is confined to changes in the skin
- C. Results in damage to the heart and lungs
- D. Affects both joints and muscles
Correct Answer: B
Rationale: Discoid lupus erythematosus primarily affects the skin, causing chronic rashes, unlike systemic lupus, which can involve multiple organs.
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.