Nokea
An adult who has chronic obstructive pulmonary disease (COPD) is receiving oxygen at home via nasal cannula. In addition to instructing the client and his family about not smoking when oxygen is in use, what should the nurse plan to include in the teaching?
- A. If the prescribed liter flow does not relieve his difficulty breathing, increase the liter flow by up to 2 L/min every four hours.
- B. Try not to shuffle across the carpeted floor.
- C. Clean the nasal cannula with alcohol several times a day.
- D. Increase the oxygen flow rate if you develop shortness of breath.
Correct Answer: B
Rationale: Shuffling across carpet generates static electricity, risking sparks near oxygen, which is a fire hazard. Adjusting oxygen flow without medical orders or cleaning with alcohol (instead of soap and water) is unsafe.
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A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
- A. I don't remember anything about what happened to me.
- B. I'd rather not talk about it right now.
- C. It's all the other guy's fault! He was going too fast.
- D. My mother is heartbroken about this.
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
A client with schizophrenia is receiving Clozaril (clozapine) 150 mg twice a day. An adverse reaction to the medication is:
- A. Photosensitivity
- B. Extreme elevations in temperature
- C. Weight gain
- D. Elevated blood pressure
Correct Answer: C
Rationale: Weight gain is a common adverse reaction to clozapine, often requiring monitoring and lifestyle interventions.
A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit
- A. tinnitus, vertigo, blurred vision.
- B. fever, malaise, anorexia.
- C. diaphoresis, confusion, tachycardia.
- D. hyperpnea, flushed face, diarrhea.
Correct Answer: C
Rationale: insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.