Nokea
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
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The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
- A. Hallucinogenic drugs create both stimulant and depressant effects.
- B. Hallucinogenic drugs induce a state of altered perception.
- C. Hallucinogenic drugs produce severe respiratory depression.
- D. Hallucinogenic drugs induce rapid physical dependence.
Correct Answer: B
Rationale: Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.
The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
- A. Increase the irrigation flow rate.
- B. Notify the physician.
- C. Administer a diuretic as ordered.
- D. Stop the irrigation and assess the catheter.
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
- A. Hematuria
- B. Muscle spasms
- C. Dizziness
- D. Nausea
Correct Answer: A
Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin inhibits platelet aggregation, reducing the risk of clot formation in transient ischemic attacks, which are precursors to stroke.