Nokea
The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention?
- A. ABG results of pH 7.35, Paco2 56, Hco3 29, Pao2 78 for a client diagnosed with COPD.
- B. Pulse oximetry reading of 89% on a two-day postsurgical total knee replacement client.
- C. Hgb of 9 g/dL and Hct of 28% on a client who is receiving the second unit of blood.
- D. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.
Correct Answer: B
Rationale: SpO2 89% post
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The nurse is planning the care of a client diagnosed with asthma and has written a problem of 'anxiety.' Which nursing intervention should be implemented?
- A. Remain with the client.
- B. Notify the health-care provider.
- C. Administer an anxiolytic medication.
- D. Encourage the client to drink fluids.
Correct Answer: A
Rationale: Remaining with the client (A) reduces anxiety through presence and reassurance. Notification (B), anxiolytics (C), and fluids (D) are secondary or unrelated.
Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?
- A. Visual stuffiness
- B. Dry cough
- C. High fever
- D. Scratchy throat
Correct Answer: C
Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.
The nursing staff on an oncology unit is interviewing applicants for the unit manager position. Which type of organizational structure does this represent?
- A. Centralized decision making.
- B. Decentralized decision making.
- C. Shared governance.
- D. Pyramid with filtered-down decisions.
Correct Answer: C
Rationale: Staff interviewing for a manager (C) reflects shared governance, empowering nurses in decisions. Centralized (A), decentralized (B), and pyramid (D) involve top-down structures.
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
A patient is newly diagnosed with COPD due to chronic bronchitis. You're providing education to the patient about this disease process. Which statement by the patient indicates they understood your teaching about this condition?
- A. If I stop smoking, it will cure my condition.'
- B. Complications from this condition can lead to pulmonary hypertension and right-sided heart failure.'
- C. I'm at risk for low levels of red blood cells due to hypoxia and may require blood transfusions during acute illnesses.'
- D. My respiratory system is stimulated to breathe due to high carbon dioxide levels rather than low oxygen levels.'
Correct Answer: B
Rationale: Chronic bronchitis can lead to pulmonary hypertension and right-sided heart failure due to chronic hypoxemia. Smoking cessation slows progression but doesn't cure, low RBCs are not typical, and CO2 drive applies to severe cases.