Nokea
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. What action should the nurse implement?
- A. Encourage the client to take deep breaths
- B. Remove the mask to deflate the bag
- C. Increase the liter flow of oxygen
- D. Document the assessment data
Correct Answer: D
Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.
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A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?
- A. INR of 3.5
- B. Prothrombin time (PT) of 15 seconds
- C. Headache
- D. Blood pressure of 140/90 mmHg
Correct Answer: C
Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.
A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?
- A. Infuse sodium chloride 0.9% (normal saline)
- B. Prepare an emergency dose of glucagon
- C. Determine the last time the client ate
- D. Check urine for ketone bodies with a dipstick
Correct Answer: A
Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.
The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
- A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
- B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
- C. Viral meningitis with a temperature change from 101°F to 102°F.
- D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.
Correct Answer: C
Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.
Which class of drugs is the only source of a cure for septic shock?
- A. Antihypertensives
- B. Anti-infectives
- C. Antihistamines
- D. Anticholesteremics
Correct Answer: B
Rationale: The correct answer is B: Anti-infectives. Anti-infective agents, such as antibiotics, are essential in treating septic shock as they can eliminate bacteria and halt the progression of the condition by stopping the production of endotoxins. Antihypertensives (Choice A) are used to lower blood pressure, antihistamines (Choice C) are used to treat allergic reactions, and anticholesteremics (Choice D) are used to lower cholesterol levels. However, none of these drug classes directly address the bacterial infection that underlies septic shock.
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
- A. Review the staff nurse job description to ensure that it is clear, accurate, and current.
- B. Conduct regular meetings to clarify roles.
- C. Increase communication between team members.
- D. Provide additional training for new nurses.
Correct Answer: A
Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.