Nokea
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.
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A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
- A. 5%
- B. 10%
- C. 15%
- D. 25%
Correct Answer: A
Rationale: Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%. Normal carboxyhemoglobin (HbCO) levels are 0% to 3% for nonsmokers and 3% to 8% for smokers. Levels of 10% to 20% cause headaches, nausea, vomiting, and dyspnea. Levels of 30% to 40% cause severe headaches, syncope, and tachydysrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Options 2, 3, and 4 are elevated levels.
The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.
A client scheduled for pneumonectomy tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?
- A. They are generally removed after 36 to 48 hours.
- B. Not every lung surgery requires chest tubes to be used.
- C. They usually remain in place for a full week after surgery.
- D. Your type of surgery rarely requires chest tubes to be inserted after surgery.
Correct Answer: D
Rationale: Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies.
The nurse notes this cardiac rhythm on the cardiac monitor (refer to figure). What should the nurse interpret that the client is experiencing?
- A. Atrial fibrillation
- B. Sinus bradycardia
- C. Ventricular fibrillation (VF)
- D. Premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: PVCs are abnormal ectopic beats (occurring in otherwise normal sinus rhythm) originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. In atrial fibrillation, no definitive P wave usually can be observed; only fibrillatory waves before each QRS complex are observed. In sinus bradycardia, atrial and ventricular rhythms are regular, and the rates are less than 60 beats per minute. In ventricular fibrillation, impulses from many irritable foci in the ventricles fire in a totally disorganized manner, which appears as a chaotic rapid rhythm in which the ventricles quiver.