Nokea
The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
- A. Oxygen used 30 feet from a gas stove
- B. Oxygen tank stored in the tank holder
- C. No smoking' sign posted at the front door
- D. Oxygen concentrator propped against a wall
Correct Answer: D
Rationale: The oxygen concentrator should be free and clear of walls or other enclosed spaces to allow adequate air circulation around the unit; otherwise, the unit can overheat and increase the risk of fire. Clients should avoid using oxygen within 10 feet of open flames because oxygen fuels a fire. Oxygen tanks are secured in a holder to stabilize and protect the tank, and a 'no smoking' sign should be in view to alert visitors about the risk.
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You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
The nurse is caring for a client with a history of chronic bronchitis who is prescribed theophylline (Theo-Dur). Which of the following symptoms indicates theophylline toxicity?
- A. Bradycardia.
- B. Tachycardia.
- C. Hypotension.
- D. Weight loss.
Correct Answer: B
Rationale: Tachycardia is a sign of theophylline toxicity, indicating the need for immediate medical evaluation.
A client is admitted to the hospital in sickle cell crisis. For which clinical indicator should the nurse monitor the client?
- A. Pain
- B. Diarrhea
- C. Bradycardia
- D. Blurred vision
Correct Answer: A
Rationale: Sickle cell crisis usually causes severe pain in the bones and joints along with joint swelling. The pain develops as a result of microvascular occlusion from abnormal sickled hemoglobin that occurs with hypoxia. Therapy includes pain management with opioid analgesics, supplemental oxygen, and intravenous fluids. The remaining options are not associated with sickle cell crisis.
What are the nursing implications associated with administering blood and blood products to a client who has a blood type of B negative?
- A. The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
- B. The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
- C. The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
- D. The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor
Correct Answer: C
Rationale: B negative blood type has anti-A agglutinins (antibodies against A antigen) and lacks the Rh factor, requiring careful matching to avoid transfusion reactions.
Which of the following should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?
- A. Cognitive and behavioral strategies.
- B. Issue avoidance and denial of problems.
- C. Rest and sleep.
- D. Withdrawal from role expectations and role relationships.
Correct Answer: A
Rationale: Cognitive and behavioral strategies, such as relaxation techniques, help clients manage anxiety effectively.