Nokea
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds.
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A, B, F
Rationale: The correct answers are A, B, and F. Increasing oxygen flow rate to 4 L/min helps improve oxygenation. Assessing breath sounds helps monitor respiratory status. Instructing the client to perform diaphragmatic breathing promotes effective breathing. Choices C and D are incorrect because chest percussion, vibration, and placing the client in a supine position are not appropriate interventions for respiratory care. Choice E is incorrect as fluid restriction may worsen respiratory conditions.
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A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time
- B. Complete an incident report if a client vomits after taking a medication
- C. Inform clients about the action of each medication prior to administration
- D. Read medication labels at least two times prior to administration
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Correct Answer: C (Fetal anemia)
Rationale: Fetal anemia can lead to decreased oxygen delivery to the fetus, causing fetal bradycardia. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the heart working harder to compensate for the decreased oxygen levels, leading to a lower fetal heart rate.
Summary of Incorrect Choices:
A: Maternal hypoglycemia - Unlikely to cause fetal bradycardia directly.
B: Chorioamnionitis - Typically presents with maternal fever and tachycardia, not fetal bradycardia.
D: Maternal fever - Can cause fetal tachycardia, not bradycardia.
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.