Nokea
The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?
- A. The client is able to talk.
- B. The client is alert and oriented.
- C. The client's O2 saturation is 97%.
- D. The client's chest movements are uninhibited.
Correct Answer: C
Rationale: An O2 saturation of 97% directly indicates adequate oxygenation from respiratory efforts. Talking (A), alertness (B), and chest movement (D) are indirect and less specific.
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A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
- A. Digoxin (Lanoxin) 0.25 mg po every day
- B. Furosemide (Lasix) 40 mg po every morning
- C. O2 2 L/min via nasal cannula
- D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
Correct Answer: A
Rationale: Digoxin enhances myocardial contractility, improving cardiac output in heart failure.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring effective treatment of infections while minimizing toxicity risks.
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
- A. High fever, tachycardia, stupor, renal failure
- B. Lip smacking, chewing, blinking, lateral jaw movements
- C. Photosensitivity, orthostatic hypotension, dry mouth
- D. Constipation, blurred vision, drowsiness
Correct Answer: B
Rationale: These symptoms are found in clients with tardive dyskinesia.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.