Nokea
Which findings indicate the client's condition has improved? (Select all that apply)
- A. Pain level
- B. Respiratory rate
- C. Heart rate
- D. Blood pressure
- E. Echocardiogram results
- F. Urinary Output
- G. Oxygenation Saturation
Correct Answer: A, B
Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress. Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.
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A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream due to inadequate ventilation. This leads to increased levels of carbonic acid, causing the blood pH to decrease. The nurse should identify this mechanism as responsible for the acid-base imbalance.
Loss of bicarbonate (B) would lead to metabolic acidosis, not respiratory acidosis. Excessive vomiting (C) would result in metabolic alkalosis. Hyperventilation (D) would actually help correct respiratory acidosis by blowing off excess carbon dioxide.
Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
A nurse is providing teaching to a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: Avoiding crowds helps reduce the risk of exposure to infections, crucial for neutropenic clients.
C: Taking temperature daily allows early detection of fever, a sign of infection.
B: Weekly toothbrush washing does not directly impact infection risk.
D: Fresh fruits and vegetables are good for health but not specific to neutropenia management.