Nokea
The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
Correct Answer: 880
Rationale: Heparin rate: (20,000 units ÷ 500 mL) × 22 mL/hr = 40 units/mL × 22 mL/hr = 880 units/hr.
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How long after administering a tuberculin skin test should the nurse inspect the client's injection site?
- A. 1 week
- B. 1 day
- C. 2 to 3 days
- D. 4 to 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction is typically read 48 to 72 hours (2 to 3 days) after administration to assess for induration.
Which assessment technique is essential before allowing a client food or fluids after a bronchoscopy?
- A. Touch the arch of the palate with a tongue blade.
- B. Listen to the abdomen for active bowel sounds.
- C. Inspect the oral mucous membranes for integrity.
- D. Palpate the throat while the client swallows.
Correct Answer: D
Rationale: Palpating the throat while the client swallows confirms the gag reflex has returned, ensuring safe oral intake post-bronchoscopy.
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.
The nurse instructs the client's spouse to empty and thoroughly clean the vaporizer after each use. Which rationale provides the basis for the nurse's instruction?
- A. There is a potential for injury if the vaporizer is accidentally knocked off a nightstand.
- B. When the vaporizer is not cleaned, there is the growth of environmental pathogens.
- C. The vaporizer can collect dust, which could affect the client's breathing.
- D. Water evaporation causes calcium deposits that will obstruct the vaporizer.
Correct Answer: B
Rationale: A cool-mist vaporizer can harbor pathogens like bacteria and mold if not cleaned properly, potentially worsening respiratory symptoms.
The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions?
- A. I will call 911 if my medications don't control an attack.
- B. I will wash my bedding in warm water.
- C. I can still eat at the Chinese restaurant when I want.
- D. If I get a headache, I should take a nonsteroidal anti-inflammatory drug.
Correct Answer: A
Rationale: Calling 911 for uncontrolled asthma (A) shows understanding of emergency action. Warm water (B) is insufficient (hot water needed), Chinese food (C) may contain MSG, and NSAIDs (D) can trigger asthma.