Nokea
What clinical manifestation is most indicative of possible carbon monoxide poisoning?
- A. Pulse oximetry reading of 80%
- B. Expiratory stridor and nasal flaring
- C. Cherry red color to the mucous membranes
- D. Presence of carbonaceous particles in the sputum
Correct Answer: C
Rationale: Cherry red mucous membranes are a hallmark of carbon monoxide poisoning due to carboxyhemoglobin formation, which gives tissues a bright red appearance.
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The nurse is teaching a client with a new diagnosis of migraine headaches about trigger avoidance. Which of the following should the client avoid?
- A. Regular exercise.
- B. Aged cheeses.
- C. Fresh fruits.
- D. Daily meditation.
Correct Answer: B
Rationale: aged cheeses contain tyramine, a common migraine trigger
A nurse working in ICU has a client on a propofol (Diprivan) drip while on the mechanical ventilator. The nurse needs another bottle, which must be picked up in person in the hospital pharmacy. Which is the correct action by the nurse concerning this medication?
- A. ask the unit secretary to go to the pharmacy and pick it up
- B. send the unlicensed assistive personnel (UAP) to pick it up since the nurse is busy
- C. ask the client's health care provider to bring it when he or she rounds on the client
- D. ask another nurse to watch the clients while the nurse goes to the pharmacy to get the medication
Correct Answer: D
Rationale: The nurse must ensure continuous client monitoring, so asking another nurse to cover while retrieving the controlled medication is the safest action.
A client who has undergone a thyroidectomy complains of numbness, tingling, and stiffness in her hands, feet, and face as well as muscle tremors, spasmodic muscle contractions, and anxiety during the postoperative period. Which laboratory tests does the nurse anticipate that the physician will request?
- A. Hemoglobin.
- B. Sodium.
- C. Thyroid-stimulating hormone (TSH).
- D. Calcium.
Correct Answer: D
Rationale: Numbness, tingling, and muscle spasms post-thyroidectomy suggest hypocalcemia due to parathyroid gland disruption. The physician will likely request a calcium level test (D). Hemoglobin (A), sodium (B), and TSH (C) are not directly related to these symptoms.
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
- A. Puffed wheat
- B. Banana
- C. Puffed rice
- D. Cornflakes
Correct Answer: A
Rationale: Puffed wheat contains gluten, which must be avoided in celiac disease to prevent intestinal damage.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.