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 of the bed
- 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 (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
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Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Phenothiazines
- B. Anticholinergics
- C. Anti-Parkinsonian drugs
- D. Tricyclic agents
Correct Answer: B
Rationale: This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. This answer is incorrect. Anti-Parkinsonian drugs would increase the symptoms. This answer is incorrect. Tricyclic agents are used for symptoms of depression.
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
- A. Bananas
- B. Broccoli
- C. Salmon
- D. Pasta
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
- A. Age of the client
- B. Frequency of intercourse
- C. Regularity of the menses
- D. Range of the client's temperature
Correct Answer: C
Rationale: The rhythm method relies on predicting ovulation based on menstrual cycle patterns. Regular menses are essential for accurate prediction. Age intercourse frequency and temperature range are less critical to its success.
Which of the following lab data is representative of a client with aplastic anemia?
- A. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
- B. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
- C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
- D. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
Correct Answer: D
Rationale: (A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.