Nokea
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
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The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The nurse is planning care for a client diagnosed with Mycoplasma pneumonia. The nurse should plan to
- A. place the client in a private room with negative airflow.
- B. wear a surgical mask within 3 feet of the client.
- C. wear gloves when in contact with the client.
- D. provide disposable meal trays and utensils.
Correct Answer: B
Rationale: Mycoplasma pneumonia requires droplet precautions, including a surgical mask within 3 feet. Negative airflow, gloves, and disposable trays are not required.
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
- A. Empty their bladder before bed.
- B. Take more naps throughout the day.
- C. Eat a high amount of calories before bed.
- D. Plan vigorous exercise earlier in the day.
- E. Use multiple nightlights in the bedroom.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The nurse supervises a student nurse preparing a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student
- A. Asks the client if they have claustrophobia.
- B. Instructs the client to apply earplugs before the exam.
- C. Moves the nitroglycerin patch from the torso to the back.
- D. Tells the client that they will not have any exposure to radiation.
Correct Answer: C
Rationale: Moving a nitroglycerin patch can disrupt medication delivery and is unnecessary for MRI. Asking about claustrophobia, using earplugs, and confirming no radiation exposure are correct.