Nokea
The nurse is to start oxygen therapy via nasal cannula. Which action is correct?
- A. Set the oxygen at 12 L/min.
- B. Lubricate the cannula with petrolatum before inserting.
- C. Give 100% oxygen by mask before inserting.
- D. Insert the cannula 1 cm into the nostrils.
Correct Answer: D
Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.
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An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding.
Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client's emotional support?
- A. My husband will be so angry with me if I lose this baby.
- B. I'm afraid I am going to lose my baby.
- C. I can't stay here. I don't have any insurance.
- D. I feel so guilty. I didn't want to get pregnant.
Correct Answer: A
Rationale: Strategy: Think about what the words mean. (1) correct-client's concern about her husband's feelings indicates that he may not be able to support her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and confusion.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.
The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?
- A. Cheeseburger with tomato and onion.
- B. Spaghetti with meat sauce and green beans.
- C. Tuna fish sandwich with orange juice.
- D. Grilled cheese sandwich and chocolate pudding.
Correct Answer: B
Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.
A client with chronic bronchitis is admitted with complaints of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin (Nitrostat)
- B. Cephalexin (Keflex)
- C. Propranolol (Inderal)
- D. Verapamil (Calan)
Correct Answer: C
Rationale: Propranolol, a beta-blocker, can exacerbate bronchoconstriction in chronic bronchitis, worsening respiratory symptoms. Nitroglycerin, cephalexin, and verapamil are less likely to pose issues in this context.