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A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
- A. Cyanosis
- B. Agitation
- C. Hypotension
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Agitation. During an asthma attack, hypoxemia can lead to decreased oxygen supply to the brain, causing agitation due to hypoxia. Cyanosis (A) is a bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia. Hypotension (C) is not typically associated with hypoxemia in asthma. Dizziness (D) is more commonly seen in conditions like hyperventilation rather than hypoxemia. In summary, agitation is the most likely manifestation of hypoxemia during an asthma attack due to decreased oxygen supply to the brain.
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A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
- A. Give the ordered KCL as prescribed.
- B. Hold the KCL and notify the healthcare provider.
- C. Administer potassium via IV push.
- D. Check the client's potassium level again in 1 hour.
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
- A. Fine crackles in the lungs
- B. Increased anteroposterior diameter of the chest
- C. Increased tactile fremitus
- D. Fever and chills
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD with emphysema, there is air trapping leading to hyperinflation of the lungs, causing the chest to expand more in the front-to-back direction (increased anteroposterior diameter). This is known as barrel chest.
A: Fine crackles are not typically associated with COPD/emphysema, they are more common in conditions like heart failure or pneumonia.
C: Increased tactile fremitus is not typically seen in COPD/emphysema, it may be present in conditions like pneumonia.
D: Fever and chills are not typical findings in COPD/emphysema unless there is an infection present.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility on the affected side.
- C. Increase independence in activities of daily living.
- D. Prevent falls during rehabilitation.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. Communication is a key aspect affected by left hemispheric CVA, which can lead to aphasia or difficulty in speaking and understanding language. By prioritizing communication goals, the nurse can enhance the client's quality of life, facilitate social interactions, and improve overall rehabilitation outcomes. Increasing mobility (B) and independence in activities of daily living (C) are important but may not directly address the communication deficits. Preventing falls (D) is also crucial but not specific to the client's primary deficit.
A nurse is assessing a client who has fluid overload. Which of the following findings shouldn't the nurse expect?
- A. Increased heart rate
- B. Increased blood pressure
- C. Increased respiratory rate
- D. Increased hematocrit
Correct Answer: D
Rationale: The correct answer is D: Increased hematocrit. In fluid overload, there is an excess of fluid in the body, leading to dilution of blood components including hematocrit. Therefore, an increased hematocrit would not be expected. Increased heart rate (A), blood pressure (B), and respiratory rate (C) are all common findings in fluid overload due to the body's compensatory mechanisms to maintain adequate perfusion. Thus, these findings are expected.
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.