Nokea
The nurse is caring for a man who has chronic emphysema and is receiving oxygen at 2 L/min. The nurse enters the room to find that his wife has turned the oxygen up to 10 L/min because her husband is having increasing difficulty breathing. What is the best immediate action for the nurse to take?
- A. Explain to the wife that his oxygen was ordered at 2 L/min and it should stay there until the physician orders something else
- B. Turn the oxygen setting back to 2 L/min
- C. Tell the wife that 10 L/min is too high and turn it back to 5 L/min
- D. Assure her that 10 L/min will ease her husband's breathing
Correct Answer: B
Rationale: High oxygen in emphysema can suppress respiratory drive, worsening hypercapnia; returning to 2 L/min is critical, followed by physician consultation.
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The nurse is caring for a client with a history of heart failure who is receiving digoxin 0.125 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Fatigue and weakness.
- B. Nausea and loss of appetite.
- C. Occasional palpitations.
- D. Mild ankle edema.
Correct Answer: B
Rationale: Nausea and loss of appetite suggest digoxin toxicity, a medical emergency. Options A, C, and D are less specific or expected in heart failure.
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
- A. He should avoid blowing his nose or cleaning his ears for two days.'
- B. I should wake him every 3 hours tonight and tomorrow night to check him.'
- C. I can give him Tylenol every 4 hours if he complains of a headache.'
- D. He will be well enough to play in his soccer game tomorrow.'
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
The nurse should advise the client that
- A. she has gained too much weight and her diet should be reevaluated.
- B. she has not gained enough weight and her diet should be reevaluated.
- C. her weight gain is appropriate and she should continue on her present diet.
- D. her weight gain indicates that she may have difficulties later in pregnancy.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question
A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
- A. Isograft
- B. Autograft
- C. Homograft
- D. Xenograft
Correct Answer: D
Rationale: A Jewish client may find a xenograft unacceptable due to religious dietary laws that prohibit the use of certain animal products, such as porcine grafts. An isograft (from an identical twin), autograft (from the client's own body), and homograft (from a human donor) are generally more acceptable. Answers A, B, and C are incorrect because they do not typically conflict with Jewish religious beliefs.
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification