Nokea
The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
- A. Notify the physician
- B. Do nothing; this is a normal O2 sat for a 9-year-old
- C. Apply oxygen
- D. Assess the child's pulse
Correct Answer: C
Rationale: An O2 sat of 78% indicates severe hypoxemia, so applying oxygen is the first action to stabilize the child.
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A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client’s urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?
- A. Mild nausea after taking the medication.
- B. Gingival hyperplasia and rash.
- C. Slight drowsiness in the morning.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. A granola bar
- B. A bran muffin
- C. Yogurt
- D. Raisins
Correct Answer: C
Rationale: Yogurt is rich in calcium, which is essential for bone health in osteoporosis management.
A client with Graves' disease is brought to the ER with a suspected thyroid storm. The nurse expects to see what signs and symptoms?
- A. seizures, jaundice, irregular heartbeat, vomiting
- B. bradycardia, septic shock, polyuria
- C. increased cranial pressure, thready pulse, rash across chest
- D. poor muscle tone, dyspnea, cyanosis
- E. None
Correct Answer: E
Rationale: Thyroid storm presents with fever, tachycardia, agitation, and sweating. None of the options fully match, but A (irregular heartbeat, vomiting) is closest, though seizures and jaundice are less typical.
The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).