Nokea
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client reports increased shortness of breath. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Check the client's oxygen saturation.
- C. Place the client in a supine position.
- D. Administer a bronchodilator as ordered.
Correct Answer: B
Rationale: checking oxygen saturation provides objective data to assess the client's respiratory status
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A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
- A. Amount of the drainage.
- B. Character of the drainage.
- C. Consistency of the drainage.
- D. Amount of suction on the drainage system.
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report
A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?
- A. Massage the client's legs to increase circulation.
- B. Elevate the knee gatch to reduce stress on the suture line.
- C. Apply thigh-high TED hose to promote venous return.
- D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C
Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation
The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
- A. Hold the next feeding.
- B. Teach the mother CPR.
- C. Maintain a normal feeding schedule.
- D. Elevate the head of the bed.
Correct Answer: D
Rationale: infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle
The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?
- A. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received RhoGAM.
- B. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies.
- C. An Rh-positive woman who previously aborted a fetus at 12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man.
- D. An Rh-negative woman who never received RhoGAM and now conceived with an Rh-negative man.
Correct Answer: B
Rationale: Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells
The nurse is preparing to begin a dopamine (Intropin) infusion on a client.
Before beginning the infusion the nurse should
- A. evaluate the urine output.
- B. obtain the client's weight.
- C. determine the patency of the IV line.
- D. measure pulmonary artery pressures.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to dopamine. (1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct-if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time