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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.
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A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?
- A. Begin cardiopulmonary resuscitation (CPR) and call a code.
- B. Ask the UAP to complete postmortem care.
- C. Report the client’s status to the healthcare provider.
- D. Notify the family of the client’s death.
Correct Answer: C
Rationale: Reporting respects DNR and ensures documentation.
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/25 mL'. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 5
Rationale: 200 mg ÷ (1000 mg/25 mL) = 5 mL.