Nokea
Which factors predispose a client to hypoxia during the immediate postoperative period?
- A. Pooling of secretions in the lungs
- B. Fluid and electrolyte loss
- C. Physical and psychological trauma
- D. Increased mobility
Correct Answer: A
Rationale: The correct answer is A because pooled secretions can obstruct airways, leading to hypoxia.
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For Mr. Jones’ persistent productive cough, what nursing action would be most appropriate?
- A. Increase intake of warm liquids
- B. Administer narcotic cough medication
- C. Monitor the amount of sputum produced each day
- D. Place the patient on strict bed rest
Correct Answer: A
Rationale: Warm liquids soothe the throat and thin mucus, facilitating expectoration.
A patient with a second-degree burn has a greater risk for
- A. Constipation.
- B. Infection.
- C. Hypotension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Burns disrupt skin integrity, increasing infection risk.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Assess the client's vital signs including oxygen saturation.
- C. Notify the Rapid Response Team immediately.
- D. Place the client in a high Fowler's position.
Correct Answer: D
Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress.
Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.
You anticipate that the physician will order which drug for status epilepticus?
- A. PO phenytoin and carbamazepine
- B. IV lorazepam (Ativan)
- C. IV carbamazepine
- D. IV magnesium sulfate
Correct Answer: B
Rationale: Lorazepam is commonly used for rapid control of seizures in status epilepticus.
A client with newly diagnosed osteoporosis is being taught about lifestyle modifications. Which instruction should be included?
- A. Increase intake of caffeinated beverages.
- B. Engage in weight-bearing exercises regularly.
- C. Avoid exposure to sunlight.
- D. Take calcium supplements with iron.
Correct Answer: B
Rationale: Step 1: Weight-bearing exercises help improve bone density and strength, crucial in managing osteoporosis.
Step 2: Regular engagement in weight-bearing exercises can reduce the risk of fractures in individuals with osteoporosis.
Step 3: Increasing intake of caffeinated beverages can contribute to bone loss.
Step 4: Avoiding exposure to sunlight can decrease vitamin D levels necessary for calcium absorption.
Step 5: Taking calcium supplements with iron may interfere with calcium absorption.
Summary: Choice B is correct as weight-bearing exercises are essential for managing osteoporosis. Choices A, C, and D are incorrect because they can have negative impacts on bone health.