Nokea
Which signs and symptoms of lithium toxicity should a nurse monitor for?
- A. Constipation
- B. Vomiting
- C. Amnesia
- D. Muscular rigidity
Correct Answer: B
Rationale: Vomiting is a common early sign of lithium toxicity, indicating the need for immediate medical attention.
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Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.
A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?
- A. Provide the client with supplemental oxygen at 5 L/min via facemask.
- B. Place the client in high-Fowler's position with their legs in a dependent position
- C. Give the client sublingual nitroglycerin
- D. Administer morphine sulfate IV
Correct Answer: A
Rationale: The correct answer is A: Provide the client with supplemental oxygen at 5 L/min via facemask. In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress, reducing the workload on the heart. This intervention addresses the client's dyspnea and anxiousness by improving oxygen delivery.
Choice B is incorrect as placing the client in high-Fowler's position with legs in a dependent position can help with breathing but does not address the immediate need for oxygenation.
Choice C is incorrect as sublingual nitroglycerin is typically used for angina and not the priority intervention for cardiogenic pulmonary edema.
Choice D is incorrect as morphine sulfate IV may be indicated for pain relief and anxiety, but it is not the priority intervention to address the client's oxygenation needs in cardiogenic pulmonary edema.
A clinical polysomnography (PSG) may be performed on a patient with signs and symptoms of a sleep disorder. What measures and observations does this study include (select all that apply)?
- A. Heart rate monitoring
- B. Noninvasive oxygen saturation (SpO2)
- C. Surface body temperature fluctuations
- D. Blood pressure monitoring (noninvasive)
Correct Answer: A
Rationale: The correct answers are A, B, E, F, G, H, and I. PSG includes heart rate, SpO2, airflow, muscle tone, respiratory effort, eye movements, and brain activity. Surface body temperature (C) and actigraphy (J) are not typically part of PSG.
What aspect of Mr. Ross’s health history is most indicative of cancer of the lung?
- A. A positive Tine test
- B. He is a vegetarian
- C. He smokes two packs of cigarettes a day
- D. He last visited a physician 2 years ago
Correct Answer: C
Rationale: Smoking is the strongest risk factor for lung cancer.
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?
- A. The student should use his quick-relief inhaler.
- B. The student's asthma is not well controlled.
- C. The student's peak flow is 50% to 80% of his best peak flow.
- D. The student needs to go to the hospital
Correct Answer: D
Rationale: The correct answer is D because the student being in the yellow zone indicates moderate symptoms, not severe enough to necessitate hospitalization. A: Using a quick-relief inhaler is appropriate for yellow zone symptoms. B: Yellow zone indicates asthma is not well controlled, supporting the need for action. C: Peak flow of 50% to 80% signals a reduction in lung function, requiring intervention but not immediate hospitalization. Thus, D is the incorrect choice because hospitalization is not warranted for yellow zone symptoms.