Nokea
If the SpO2 level is above 90%, what can be assumed about the PaO2?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.
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While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
- A. Bowel sounds
- B. Surgical dressing
- C. Temperature
- D. Oxygen saturation
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation. The priority assessment after a cholecystectomy is monitoring the client's oxygen saturation to ensure adequate oxygenation post-surgery. Decreased oxygen saturation can indicate respiratory distress, which requires immediate intervention. Bowel sounds (A) are important but not the priority post-cholecystectomy. Surgical dressing (B) should be assessed, but it is not as critical as monitoring oxygen saturation. Temperature (C) is also important, but ensuring oxygenation takes precedence in the immediate postoperative period.
What strategies could decrease the distress of rotating shifts for nurses (select all that apply)?
- A. Take a brief onsite nap
- B. Use sleep hygiene practices
- C. Sleep just before going to work
- D. Maintain consistent sleep/wake schedules even on days off (if possible)
Correct Answer: A
Rationale: The correct answers are A, B, and D. Brief naps (A), sleep hygiene (B), and consistent schedules (D) improve adaptation to shift work. Sleeping just before work (C) can worsen sleep quality.
What outcome criterion would best reflect achievement of avoiding infections for Mr. Puff?
- A. Explains reason for avoiding aerosol sprays and powders
- B. Explains reason for avoiding unnecessary physical activity
- C. Lists causative organisms of bronchial infections
- D. States rationale for avoiding crowds when influenza or colds are prevalent
Correct Answer: D
Rationale: Avoiding crowded places minimizes exposure to respiratory pathogens.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.