Nokea
A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home.
Which of the following actions should the nurse take?
- A. Place the oxygen tank away from curtains or drapes.
- B. Store extra oxygen tanks in a closed closet.
- C. Lay the oxygen tank on its side when not in use.
- D. Increase the oxygen flow rate if the client reports shortness of breath.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Placing the oxygen tank away from curtains or drapes reduces the risk of fire hazards since oxygen supports combustion. This action ensures a safe environment for the client.
Summary:
B: Storing extra oxygen tanks in a closed closet is a good practice, but not directly related to immediate safety concerns like fire hazards.
C: Laying the oxygen tank on its side when not in use can cause damage to the tank and is not a safe storage method.
D: Increasing the oxygen flow rate without proper assessment can be dangerous and may worsen the client's condition.
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Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
The nurse is continuing to care for the client.
Diagnostic Results Day 1,
1000:
Appearance cloudy (clear) Color
yellow (yellow)
pH 5.9 (4,6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03) Leukocyte esterase
negative (negative)
Nitrites negative (negative) Ketones
negative (negative) Crystals negative
(negative) Casts negative (negative)
Glucose trace (negative) WBC 5 (0
to 4)
WBC casts none (none)
RBC 1 (less than or equal to 2) RBC
casts none (none)
Day 1, 1030:
CBC:
Nurses' Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances. +3 pitting edema in bilateral lower extremities, Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted
The client is at greatest risk for developing -----and-------
- A. Placental abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical Insufficiency
- E. Seizures
Correct Answer: A,E
Rationale: The correct answer is A (Placental abruption) and E (Seizures) because they are common complications during pregnancy. Placental abruption poses a risk of severe bleeding and fetal distress, leading to adverse outcomes. Seizures, specifically eclampsia, can occur due to uncontrolled hypertension in pregnancy, putting both the mother and baby at risk. Hypoglycemia (B), heart failure (C), and cervical insufficiency (D) are potential complications but are not the greatest risks compared to placental abruption and seizures in this context.
A nurse is preparing to initiate intravenous fluids via pump for a client.
which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Ensure the IV tubing is primed and free of air bubbles before connecting it to the client
- C. Position the IV pump below the level of the client's heart to prevent rapid infusion
- D. Select a catheter gauge of 12 to ensure adequate fluid flow
Correct Answer: B
Rationale: The nurse should choose option B: Ensure the IV tubing is primed and free of air bubbles before connecting it to the client. This is crucial to prevent air embolism, which can be life-threatening. Priming the tubing ensures that only fluid is infused into the client's bloodstream. Air bubbles can travel to the heart and lungs, causing blockages and impairing circulation. Positioning the IV pump below the client's heart (option C) is incorrect as it can lead to rapid infusion and potential complications. Selecting a catheter gauge of 12 (option D) is not always necessary; the appropriate gauge depends on the client's condition and prescribed therapy. Obtaining a surge protector (option A) is irrelevant to the safe administration of IV therapy.
A nurse is caring for a client who has placenta previa.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, Providing constant care is very stressful and is affecting all areas of my life.
Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.