Nokea
The nurse has just admitted a client with emphysema. Arterial blood gas results indicate hypoxia. Which physician prescription would the nurse implement for the best improvement in the client's hypoxia?
- A. Elevate the head of the bed 45°
- B. Encourage diaphragmatic breathing
- C. Initiate an Alupent nebulizer treatment
- D. Start Oâ‚‚ at 2 L/min
Correct Answer: D
Rationale: Low-flow oxygen (2 L/min) directly addresses hypoxia in emphysema by improving arterial oxygen levels, making it the most effective intervention.
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The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
A diabetic client self-administers insulin four times daily. Which of the following statements by the client indicates the need for further education?
- A. I flush the used needles down the toilet.'
- B. I carry glucose tablets with me at all times.'
- C. I eat a little dessert occasionally.'
- D. I avoid wearing sandals.'
Correct Answer: A
Rationale: Flushing needles down the toilet (A) is unsafe and improper disposal; needles should be placed in a sharps container. Carrying glucose tablets (B), occasional desserts (C), and avoiding sandals (D) are appropriate for diabetes management.
A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should:
- A. Call the doctor immediately
- B. Slow the intravenous infusion
- C. Listen to the lungs for rales
- D. Administer a diuretic
Correct Answer: B
Rationale: A CVP of 2 cm of water is low, suggesting hypovolemia; slowing the IV infusion prevents fluid overload while addressing the issue.
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
- A. There is a sudden decrease in output.
- B. The NGT is set to low continuous suction.
- C. The NGT is set to medium intermittent suction.
- D. The patient is positioned in the semi-Fowler's position.
- E. The client dislodges the tube and the nurse replaces it, confirming placement by X-ray before use.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.