Nokea
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate?
- A. 2 to 3 liters per minute
- B. 4 to 5 liters per minute
- C. 6 to 8 liters per minute
- D. 8 to 10 liters per minute
Correct Answer: A
Rationale: In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen.
You may also like to solve these questions
When a hospitalized child develops a rash that covers the trunk and extremities, the nurse notes in the history that the child was exposed to varicella 2 weeks ago. Which nursing intervention has priority?
- A. Immediately reassign the child's roommate.
- B. Place the child in a private room on strict isolation.
- C. Confirm the exposure occurred with the child's parent.
- D. Assess the progression of the rash and report it to the primary health care provider.
Correct Answer: B
Rationale: The child with undiagnosed rash needs to be placed on strict isolation. Varicella causes a profuse rash on the trunk with a sparse rash on the extremities. The incubation period is 14 to 21 days. It is important to prevent the spread of this communicable disease by placing the child in isolation until further diagnosis and treatment are made. None of the other options address the need to prevent the spread of the disease.
A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?
- A. I need to use the back burners for cooking.
- B. I need to remain in the kitchen when I prepare meals.
- C. I need to be sure to place my cup of coffee on the counter.
- D. I need to turn pot handles inward and to the middle of the stove.
Correct Answer: C
Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.
The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN?
- A. Asking the client to take sips of water
- B. Asking the client to lie down on his right side
- C. Asking the client to look up at the ceiling for 30 seconds
- D. Instructing the client to void before taking the medication
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication.
A client reporting abdominal pain has a diagnosis of acute abdominal syndrome but the cause has not been determined. Which prescription should the nurse question at this time?
- A. Clear liquid diet only
- B. Insertion of a nasogastric tube
- C. Administration of an analgesic
- D. Insertion of an intravenous (IV) line
Correct Answer: A
Rationale: Until the cause of the acute abdominal syndrome is determined and a decision about the need for surgery is made, the nurse would question a prescription to give a clear liquid diet. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression of the stomach. Pain management with medications that do not alter level of consciousness can decrease diffuse abdominal pain and rigidity, help with localizing the pain, and lead to more prompt diagnosis and treatment.
The nurse assisting in the care of a client who is to be cardioverted should plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
- A. 50 to 100 joules
- B. 200 to 250 joules
- C. 250 to 300 joules
- D. 350 to 400 joules
Correct Answer: A
Rationale: Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. Cardioversion is usually started at 50 to 100 joules. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the primary health care provider, and the remaining options identify energy levels that are too high for cardioversion.