Nokea
The nurse is discussing various oxygen delivery systems with a newly graduated nurse who has just begun working on the medical floor. Which statement by the student nurse indicates an understanding of the different oxygen delivery systems?
- A. A tracheostomy collar requires a flow rate of at least 6 L/minute to be effective.
- B. High-flow oxygen delivery systems include the venturi mask, face tent, and non-rebreather masks.
- C. The non-rebreather mask should receive a high enough flow rate to keep the reservoir bag completely full.
- D. Nasal cannulas, non-rebreather masks, simple face masks, and partial rebreather masks are examples of low-flow oxygen delivery systems.
Correct Answer: C
Rationale: Non-rebreather masks require sufficient flow to keep the reservoir bag full (C) for high FiO2. Tracheostomy collars vary (A), venturi is high-flow but face tent/non-rebreather are not (B), and non-rebreather is high-flow (D).
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A client presents to the ED with complaints of sweating, heart palpitations, vertigo, and the urge to lay down shortly after eating. The nurse anticipates which diagnosis for this client?
- A. appendicitis
- B. cholecystitis
- C. ulcerative colitis
- D. dumping syndrome
Correct Answer: D
Rationale: Postprandial sweating, palpitations, vertigo, and urge to lie down suggest dumping syndrome (D), common after gastric surgery. Appendicitis (A), cholecystitis (B), and ulcerative colitis (C) present differently.
The nurse is caring for a two-year-old client who presented to the ER with vomiting, currant jelly-like stools, and abdominal pain that causes the child to draw the knees up to the abdomen in a fetal position. Which interventions does the nurse anticipate for this client?
- A. assessing for respiratory distress
- B. orders for a soft diet as tolerated
- C. monitoring for a normal, brown stool
- D. preparing the client for a barium enema
- E. placement of a nasogastric (NG) tube
- F. monitoring for fever and changes in blood pressure
Correct Answer: C,D,E,F
Rationale: Symptoms suggest intussusception. Anticipated interventions include monitoring for normal stool (C), preparing for barium enema (D), NG tube (E), and monitoring fever/BP (F). Respiratory distress (A) and soft diet (B) are not priorities.
The nurse is caring for a client with a diagnosis of upper GI bleeding. Which findings on physical assessment are consistent with this diagnosis?
- A. increased heart rate
- B. decreased heart rate
- C. increased hemoglobin
- D. bounding peripheral pulses
Correct Answer: A
Rationale: Upper GI bleeding causes hypovolemia, leading to increased heart rate (A) to compensate. Decreased heart rate (B), increased hemoglobin (C), and bounding pulses (D) are inconsistent with blood loss.
A client has arterial blood gases drawn. The results are as follows: pH, 7.58; PaCO2, 48 mm Hg; HCO3, 44 mEq/L, Base Excess, +13 mEq/L. Which condition is indicated?
- A. respiratory alkalosis
- B. respiratory acidosis
- C. metabolic alkalosis
- D. metabolic acidosis
Correct Answer: C
Rationale: pH 7.58, HCO3 44, and base excess +13 indicate metabolic alkalosis (C). PaCO2 48 is slightly elevated but not compensatory for respiratory conditions (A, B, D).
The nurse is caring for a client at risk for postpartum hemorrhage. Which early sign of hemorrhage should the nurse monitor for this client?
- A. coma
- B. hypotension
- C. restlessness
- D. cool, clammy skin
Correct Answer: C
Rationale: Restlessness (C) is an early sign of hemorrhage due to decreased oxygen delivery. Coma (A) and hypotension (B) are late signs, and cool, clammy skin (D) is less specific early on.