Nokea
The nurse is working with a nursing student to administer an enema solution to a client. The client states she feels painful cramping. The nurse should intervene by
- A. squeezing the enema bag so the flow rate is faster.
- B. explaining to the client that this is a normal feeling and continuing with the enema.
- C. clamping the tube for 1 minute and then starting the enema at a slower rate.
- D. discontinuing the enema until the provider can order a PRN pain medication.
Correct Answer: C
Rationale: Painful cramping during an enema suggests too-rapid administration. Clamping briefly and slowing the rate reduces discomfort.
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A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
- A. Third-degree burns to the face and neck area, with singed nasal hairs
- B. Second-degree burns to each leg and thigh area, who is alert and oriented
- C. A chemical burn that has been removed and liberally flushed before admission
- D. An electrical burn entering and leaving on the same side of the body
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
- A. Loss of coordination
- B. Respiratory depression
- C. Visual hallucinations
- D. Tachycardia
Correct Answer: B
Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.
The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A. A 23-year-old female complaining of headache and nausea
- B. A 76-year-old male complaining of dysuria
- C. A 56-year-old male complaining of exertional shortness of breath
- D. A 42-year-old female complaining of recent sexual assault
Correct Answer: C
Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.
The nurse has just administered morphine 4 mg IV to a client with severe pain from a kidney stone. The client then asks to get up to the toilet. Which is the correct nursing action for this client?
- A. assist the client to the toilet
- B. offer the client a bedpan or urinal
- C. obtain an order for a Foley catheter
- D. place a bedside commode in the room
Correct Answer: B
Rationale: Morphine can cause sedation and dizziness, increasing fall risk. Offering a bedpan or urinal is safer than ambulating to the toilet.