Nokea
Prior to suctioning a tracheotomy, the nurse should:
- A. Suction the oropharynx.
- B. Administer oxygen.
- C. Change the inner cannula.
- D. Raise the head of the bed.
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.
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The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
- A. Report this immediately to the nurse manager
- B. Confront the nurse about the suspected drug use
- C. Sign the narcotic sheet and document the event in an incident report
- D. Counsel the colleague about the risky behaviors
Correct Answer: A
Rationale: The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the nurse advise the client to avoid?
- A. Fresh spinach.
- B. Lean chicken breast.
- C. Canned sardines.
- D. Whole-grain pasta.
Correct Answer: C
Rationale: Canned sardines are high in purines, which increase uric acid levels and exacerbate gout. Options A, B, and D are suitable: spinach is low-purine, chicken is lean, and whole-grain pasta is not restricted.