Nokea
When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct Answer: C
Rationale: The maximum flow rate for a nasal cannula is 6 liters/minute to avoid drying nasal passages and discomfort. Higher rates require a mask. Reduction of Risk Potential
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The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
- A. use any sedatives.
- B. become constipated.
- C. use atropine in any form.
- D. release my emotions by crying.
Correct Answer: C
Rationale: Atropine increases intraocular pressure, worsening glaucoma, indicating correct understanding.
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose if which of the following was observed?
- A. Presence of premature ventricular contractions.
- B. Occurrence of severe hypotension.
- C. Recurring paroxysmal atrial tachycardia.
- D. A sedimentation rate of 10.
Correct Answer: B
Rationale: Procainamide treats ventricular and atrial arrhythmias, but severe hypotension is an adverse reaction requiring the dose to be withheld. PVCs (A) and atrial tachycardia (C) are indications for use, and a normal sedimentation rate (D) is irrelevant.
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
Which of the following findings is most typical of a client with a fractured hip?
- A. Pain in the hip and affected leg
- B. Diminished sensation in the affected leg
- C. Absence of pedal and femoral pulses in the affected extremity
- D. Disalignment of the affected extremity
Correct Answer: A
Rationale: Pain in the hip and leg is the most typical symptom of a hip fracture. Diminished sensation, absent pulses, or disalignment may occur but are less common.
The physician orders high protein, high calorie and high salt diet on Valerie.
When ask by the patient, the nurse would explain that
- A. high salt diet replaces potassium loss in the urine.
- B. high protein, high calorie diet is needed for tissue repair and energy expenditure.
- C. high protein and high calorie diet is important in gaining weight.
- D. extra salt is needed to increase the low sodium level in Addison's disease.
Correct Answer: D
Rationale: Lack of mineralcorticoids (aldosterone) leads to a loss of sodium ions in the urine and subsequent hyponatremia, necessitating a high salt diet.