Nokea
When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?
- A. Ensure that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling the cannula
Correct Answer: B
Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.
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A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis?
- A. Low serum albumin
- B. High serum cholesterol
- C. Abnormally low white blood cell count
- D. Elevated creatinine phosphokinase (CPK)
Correct Answer: D
Rationale: The correct answer is D: Elevated creatinine phosphokinase (CPK). Elevated CPK levels indicate muscle damage, including damage to the cardiac muscle, which aligns with the diagnosis of myocardial infarction.
Choice A, low serum albumin, is not directly related to myocardial infarction. Choice B, high serum cholesterol, is more associated with conditions like atherosclerosis rather than acute myocardial infarction. Choice C, abnormally low white blood cell count, is typically not a lab value associated with myocardial infarction; instead, it could suggest other conditions like infections or bone marrow issues.
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:
- A. The complaints of at least 3 common findings.
- B. The absence of any opportunistic infection.
- C. CD4 lymphocyte count is less than 200.
- D. Developmental delays in children.
Correct Answer: C
Rationale: The correct answer is C. A CD4 count less than 200 cells/mm³ is a diagnostic criterion for AIDS. Choices A, B, and D are incorrect. Choice A is vague and does not reflect the diagnostic criteria for AIDS. Choice B is not accurate, as the presence of opportunistic infections, not their absence, is indicative of AIDS. Choice D is unrelated to the diagnosis of AIDS in adults.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to:
- A. Reports of difficulty falling and staying asleep
- B. Expression of persistent suicidal thoughts
- C. Lack of enjoyment in usual pleasures
- D. Reduced senses of taste and smell
Correct Answer: C
Rationale: The correct answer is C: Lack of enjoyment in usual pleasures. Anhedonia is the inability to feel pleasure in normally pleasurable activities. Choice A, reports of difficulty falling and staying asleep, is more indicative of insomnia rather than anhedonia. Choice B, expression of persistent suicidal thoughts, is related to suicidal ideation and not anhedonia. Choice D, reduced senses of taste and smell, is more associated with disturbances in the sense of taste and smell, not anhedonia.
Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:
- A. health deficit
- B. health deficit and health threat
- C. health threat
- D. foreseeable crisis
Correct Answer: C
Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.
When a nurse from the surgical department is reassigned to the pediatric unit, the charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
- A. Congenital cardiac defects
- B. An acute febrile illness
- C. Prolonged hypoxemia
- D. Severe multiple trauma
Correct Answer: C
Rationale: The correct answer is C, 'Prolonged hypoxemia.' Prolonged hypoxemia is a critical condition that requires specialized pediatric care due to the high risk of cardiac arrest. The other choices, such as congenital cardiac defects, acute febrile illness, and severe multiple trauma, may also require attention, but prolonged hypoxemia poses the highest risk for cardiac arrest and demands specialized expertise in managing pediatric patients with this condition.