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The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
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A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
The nurse has a client with knee surgery who is receiving patient-controlled analgesia (PCA) of meperidine (Demerol). Which assessment finding would be a priority due to the use of this device and medication?
- A. Pulse rate 108
- B. $100 \mathrm{cc}$ of green emesis
- C. Respiratory rate of 10
- D. Lack of pain relief
Correct Answer: C
Rationale: The patient is in danger of respiratory depression due to narcotic administration; therefore, this would be a priority assessment. Answer A does not relate to the PCA, so it is incorrect. Answer B is not a priority, making it wrong. Pain relief in answer D is important, but not as important as airway, so it is incorrect.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
Which of the following clients is at highest risk for developing Sarcordosis?
- A. A 40-year-old Caucasian with a history of bronchitis atrial tachycardia
- B. A 30-year-old African-American who is pregnant
- C. A 50-year-old Asian male with emphysema
- D. A 60-year-old Hispanic male with cancer
Correct Answer: B
Rationale: Sarcoidosis is most common in African-Americans, particularly women of childbearing age, making the pregnant 30-year-old African-American the highest risk.
The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client?
- A. Allow the client to continue to exercise per usual routine
- B. Assist the client in reflecting on triggers of disordered eating
- C. Document the client's daily intake of calories and protein
- D. Remain with the client for the duration of each meal
- E. Weigh the client each morning prior to any oral intake
Correct Answer: B,C,D,E
Rationale: Reflecting on triggers (B), documenting intake (C), staying during meals (D), and daily weighing (E) support recovery. Exercise (A) should be limited to prevent calorie expenditure.