Nokea
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
- A. 1-2 L/min via nasal cannula.
- B. 4-6 L/min via face mask.
- C. 8-10 L/min via non-rebreather mask.
- D. 12-15 L/min via Venturi mask.
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.
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A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?
- A. Instruct the client about the need to collect urine for 24 hours.
- B. Prepare to insert an indwelling urethral catheter.
- C. Provide the client with a sterile urine collection container.
- D. Instruct the client to force fluids to 3,000 mL/day.
Correct Answer: A
Rationale: A creatinine clearance test requires a 24-hour urine collection to assess kidney function accurately, making this the appropriate preparation.
A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?
- A. Administer pantoprazole intravenously.
- B. Insert a nasogastric tube.
- C. Administer vitamin K.
- D. Position the client supine.
Correct Answer: A
Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
- A. Monitor blood glucose levels for elevation.
- B. Administer the medication on an empty stomach only.
- C. Apply pressure to venipuncture sites for at least 2 minutes.
- D. Provide the client with a soft toothbrush and an electric razor.
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
- A. Having suction equipment readily available
- B. Keeping all the lights on in the room at night
- C. Keeping a padded tongue blade at the bedside
- D. Assisting the client to ambulate in the hallway
- E. Monitoring the client closely while showering
- F. Locking the client's bed in its lowest position
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
- A. Sterile items ONLY are placed on the sterile field.
- B. The nurse must keep the sterile field below waist level.
- C. Coughing or sneezing over the sterile field contaminates the sterile field.
- D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
- E. Moisture and wetness contaminate the sterile field.
- F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).