Nokea
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings would be of GREATest concern to the nurse?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% is low, indicating hypoxemia, a serious complication of propofol due to respiratory depression, requiring immediate intervention. Options A, B, and C are acceptable: respiratory rate 12 breaths/min, blood pressure 100/60 mmHg, and heart rate 80 bpm are stable.
You may also like to solve these questions
A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
- A. What is your reason for wanting such a plan?
- B. Have you talked with your provider about this?
- C. Let us discuss your rights as a couple
- D. Write your ideal plan for the next class
Correct Answer: C
Rationale: Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan.
The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results should the nurse report immediately?
- A. Creatinine 2.0 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates nephrotoxicity, a serious gentamicin side effect. Options B, C, and D are normal.