Nokea
The nurse must know that the most accurate oxygen delivery system available is
- A. the Venturi mask
- B. nasal cannula
- C. partial non-rebreather mask
- D. simple face mask
Correct Answer: A
Rationale: The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 53%.
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A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
A psychiatric nurse is assigned to conduct an admission nursing history on a new client.
- A. What should the admission nursing history for a new psychiatric client include?
- B. The nurse’s opinion regarding the mental and emotional status of the client.
- C. Data addressing the client’s emotional state.
- D. Data that address a biopsychosocial approach, including a family system assessment.
- E. Specific data detailing the client’s mental status.
Correct Answer: C
Rationale: A comprehensive psychiatric nursing history should use a biopsychosocial approach, including physical, psychological, social, and family system assessments, to provide a holistic understanding of the client’s needs. Focusing only on emotional state or mental status is too narrow, and the nurse’s opinion lacks objectivity without assessment data.
A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary
The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.
The nurse is assisting the physician with the insertion of a central venous catheter. Which statement best explains the rationale for placing the client in Trendelenburg position?
- A. It will make catheter insertion easier.
- B. It will make the client more comfortable.
- C. It will prevent ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: Trendelenburg position elevates the veins, making central venous catheter insertion easier. Comfort , tachycardia , and emboli are not primary concerns.