Nokea
The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
- A. The rate of respirations
- B. The absence of cyanosis
- C. Arterial blood gases
- D. The level of consciousness
Correct Answer: C
Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.
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The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintaining the client's systolic blood pressure at 70 mmHg or greater
- B. Maintaining the client's urinary output greater than 300 cc per hour
- C. Maintaining the client's body temperature of greater than 33°F rectal
- D. Maintaining the client's hematocrit at less than 30%
Correct Answer: A
Rationale: Adequate blood pressure ensures organ perfusion for donation.
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
- A. There was damage to the hypothalamus.
- B. He has an infection from the abrasions to the head and face.
- C. He will require a cooling blanket to decrease the temperature.
- D. There was damage to the frontal lobe of the brain.
Correct Answer: B
Rationale: Infection from abrasions is the most likely cause of fever post-accident, as it's a common complication.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.
In many cultures, pregnancy is viewed as a natural rather than a medical condition. How does this affect prenatal care?
- A. Pregnant women often seek prenatal care later and less frequently.
- B. These views have little effect on prenatal care.
- C. Pregnant women believe prenatal care is harmful to the fetus.
- D. These views often result in increased rates of fetal mortality.
Correct Answer: A
Rationale: Viewing pregnancy as natural (A) often leads to delayed or less frequent prenatal care, impacting monitoring. Harmful beliefs (C) or increased mortality (D) are not directly implied.
The nurse is caring for a client with a long history of taking magnesium hydroxide for managing symptoms of peptic ulcer disease. Which finding in the client's medical history would be of concern to the nurse?
- A. asthma
- B. arthritis
- C. heart failure
- D. enlarged prostate
Correct Answer: C
Rationale: Magnesium hydroxide can cause fluid retention, worsening heart failure. Other conditions are not directly affected.