Nokea
The nurse is caring for a client with a non-rebreather mask. Which is the priority nursing action when caring for this client?
- A. maintain the mask snugly on the face
- B. adjust flow rate to keep the reservoir bag inflated
- C. ensure that the reservoir bag is not kinked or twisted
- D. ensure that valves open during expiration and close on inhalation
Correct Answer: B
Rationale: Adjusting the flow rate to keep the reservoir bag inflated ensures adequate oxygen delivery, the primary goal of a non-rebreather mask.
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Which of the following conditions may cause an increased respiratory rate?
- A. Stooped posture
- B. Narcotic analgesics
- C. Injury to the brain stem
- D. Anemia
Correct Answer: D
Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen.
Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
- A. I can have a cup of fresh fruit as a snack.
- B. Baked ham is a good dinner choice for me.
- C. I need to check the label for sodium in ketchup.
- D. I need to cut out frozen pizza as a fast meal option.
Correct Answer: B
Rationale: Baked ham is high in sodium, which is unsuitable for hypertension. Other choices align with low-sodium dietary recommendations.
The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow?
- A. Keep glucose tablets.
- B. Monitor the urine for acetone.
- C. Report any feelings of drowsiness.
- D. Omit the evening dose of NPH insulin if the client has been exercising.
Correct Answer: A
Rationale: Glucose tablets are taken if a hypoglycemic reaction occurs. Glucagon is also a medication that may be prescribed to be administered subcutaneously or intramuscularly if the client loses consciousness and is unable to take glucose by mouth. Glucagon releases glycogen stores and raises the blood glucose levels of hypoglycemic clients. Family members can be taught to administer this medication and possibly to prevent an emergency department visit. Acetone in the urine may indicate hyperglycemia. Although signs/symptoms of hypoglycemia need to be taught to the client, drowsiness is not the initial and key sign of this complication. The nurse should not instruct a client to omit insulin.
A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance?
- A. Crush the tablets before taking them.
- B. Mix the tablet uncrushed in applesauce.
- C. Purchase the liquid preparation with the next refill.
- D. Call the primary health care provider for a change in medication.
Correct Answer: A
Rationale: Buspirone tablets may be crushed and administered without regard to meals, making this the most effective instruction to promote compliance for a client who finds swallowing difficult. Mixing the tablet uncrushed in applesauce does not address the swallowing issue. Buspirone is not available in liquid form, and calling the primary health care provider for a medication change is premature before trying this intervention.
The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?
- A. Sodium restriction
- B. Increased fat intake
- C. Decreased carbohydrates
- D. Calorie restriction of 1500 daily
Correct Answer: A
Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000 . The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.