Nokea
You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?
- A. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis
- B. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent
- C. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on an insulin drip
- D. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
Correct Answer: B
Rationale: A client with stable ABGs and ventilator dependence is less complex compared to other options, making them suitable for a step-down nurse temporarily working in ICU.
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Symptoms of an ectopic pregnancy include:
- A. Hematuria, pelvic pain, and dizziness
- B. Amenorrhea, pelvic pain, and vaginal spotting
- C. Constipation, nausea, and fainting
- D. Fallopian pain, nausea, and breast enlargement
Correct Answer: B
Rationale: Ectopic pregnancies often present with amenorrhea, pelvic pain, and vaginal spotting due to the abnormal implantation site.
What is contraindicated for a client being treated for Ménière’s disease?
- A. Alcohol
- B. Smoking
- C. A high-protein diet
- D. Cough syrups and other CNS depressants
Correct Answer: D
Rationale: CNS depressants can worsen dizziness and imbalance associated with Ménière’s disease.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
Why might a client receive a central venous catheter?
- A. Client is receiving 0.9 normal saline
- B. Client is receiving total parenteral nutrition (TPN)
- C. Client is receiving short-term IV therapy
- D. Client has had one infiltrated IV
Correct Answer: B
Rationale: The correct answer is B because TPN requires a central venous catheter due to the high osmolarity of the solution.
Which teaching strategies should be used when it is difficult to reach the desired goals of the session (select all that apply)?
- A. DVD
- B. Role play
- C. Discussion
- D. Printed material
Correct Answer: B
Rationale: The correct answers are 'Role play,' 'Discussion,' and 'Lecture-discussion.' These strategies encourage active participation and engagement, which can help overcome barriers to achieving learning goals. DVDs and printed materials may not engage the patient as effectively in challenging situations.