Nokea
The patient asks you what the clip on his finger is for. The best response is
- A. This is a cardiac monitor that alerts us to any arrhythmia that you might experience during the night.
- B. This measures your temperature.
- C. This is pulse oximetry and is used to give us an idea of how much oxygen is in your blood.
- D. This tells us the number of red blood cells you have. These cells provide oxygen throughout your body.
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation in the blood.
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During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems.
Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations.
Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations.
Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.
The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0°F (35.6°C). What treatment also may be used to treat the patient?
- A. Oxygen
- B. Vasodilating drugs
- C. Antidysrhythmic drugs
- D. Analgesics or sedatives
Correct Answer: A
Rationale: Shivering increases oxygen demand; providing oxygen supports metabolic needs.
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For
which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
What findings indicate tension pneumothorax causing mediastinal shift?
- A. Diminished breath sounds on left side; trachea deviated to right; decreasing blood pressure, increasing pulse rate
- B. Rapid, shallow respirations; trachea deviated to left; slow pulse; collapsed neck veins
- C. Dyspnea; hyperresonance on right; widened pulse pressure; rapid, bounding pulse
- D. Chest pain; cyanosis; collapsed neck veins; decreasing pulse rate
Correct Answer: A
Rationale: Tension pneumothorax causes unilateral lung collapse, mediastinal shift, hypotension, and tachycardia.
If a client’s parathyroid glands were accidentally removed during a procedure, which condition should the nurse prepare for?
- A. Hypomagnesemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypocalcemia
Correct Answer: D
Rationale: Parathyroid glands regulate calcium levels. Their removal leads to hypocalcemia due to decreased parathyroid hormone production.