Nokea
Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?
- A. Reduced cardiac output
- B. Disrupted surfactant production
- C. Hyperactivity of alveoli
- D. Increased oxygen carrying capacity
Correct Answer: B
Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.
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A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct Answer: B
Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.
A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?
- A. Increase fluid intake to prevent crystalluria.
- B. Take the medication with meals to prevent GI upset.
- C. Avoid sunlight exposure while taking the medication.
- D. Report any changes in the color of urine.
Correct Answer: A
Rationale: The correct answer is to increase fluid intake to prevent crystalluria, a potential side effect of ciprofloxacin. Crystalluria is the formation of crystals in the urine, which can be reduced by maintaining adequate hydration. Choice B is incorrect because ciprofloxacin can be taken with or without food. Choice C is incorrect as avoiding sunlight exposure is more relevant for medications that cause photosensitivity, not typically a concern with ciprofloxacin. Choice D is less essential than choice A because while reporting changes in urine color is important, preventing crystalluria through adequate fluid intake is a higher priority.
A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
- A. Encourage the client to eat large meals in one sitting.
- B. Offer the client frequent snacks of foods he enjoys.
- C. Provide the client with foods high in fiber to improve digestion.
- D. Discourage eating late at night to prevent weight gain.
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?
- A. Monitor the client's hemoglobin and hematocrit.
- B. Monitor the client's blood pressure.
- C. Assess the client for signs of infection.
- D. Monitor the client for signs of bleeding.
Correct Answer: A
Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.
A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?
- A. Platelet count
- B. Prothrombin time (PT)
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: B
Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.