Nokea
The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?
- A. peak expiratory flow rate reading
- B. arterial blood gas analysis
- C. pulse oximetry reading
- D. CT scan of the chest
Correct Answer: B
Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.
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An adult male has an IV in the left arm. The client calls the nurse and says that his left arm hurts. The LPN checks the IV site and notes that it is cool and blanched and not running well. What should the LPN do at this time?
- A. Flush the IV with normal saline
- B. Remove the IV immediately and start a new line
- C. Tell the charge nurse that the client's IV appears to be infiltrated
- D. Ask the charge nurse to check to see if the client has phlebitis
Correct Answer: B
Rationale: Cool, blanched skin and poor flow indicate infiltration; removing the IV and starting a new line prevents tissue damage.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn?
- A. Choose an infant carrier with a narrow seat
- B. Place 2 diapers on the infant at all times
- C. Swaddle the infant with hips flexed and abducted
- D. Use an infant swing that keeps both legs straight
Correct Answer: C
Rationale: Swaddling with hips flexed and abducted promotes healthy hip development and reduces dysplasia risk. Narrow carriers and straight-leg swings increase risk, and double diapering is outdated and ineffective.
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
The nurse is reviewing new medication prescriptions for a client with asthma and nasal polyps. The nurse should clarify the prescription for
- A. ibuprofen
- B. vitamin D
- C. albuterol
- D. montelukast
Correct Answer: A
Rationale: Ibuprofen should be clarified in asthma with nasal polyps due to risk of aspirin-exacerbated respiratory disease. Vitamin D , albuterol , and montelukast are safe.