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Questions 164

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Extract:

Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0


Question 1 of 5

The nurse recognizes which of the following factors as possibly contributing to a sentinel event?

Correct Answer: A

Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.

Extract:


Question 2 of 5

What nursing action is essential when oxygen is ordered for a client who is living at home?

Correct Answer: A

Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.

Question 3 of 5

The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?

Correct Answer: D

Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.

Question 4 of 5

A 79-year-old client asks the nurse if she needs any shots. She reports having had 'all the usual shots when I was younger.' Which immunization is most important for this person to receive?

Correct Answer: C

Rationale: Pneumovax is critical for adults over 65 to prevent pneumococcal pneumonia, a significant risk in the elderly.

Question 5 of 5

The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the

Correct Answer: D

Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.

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