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The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.
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The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation should provide which information? Select all that apply.
- A. Eat bland foods.
- B. Avoid alcohol ingestion.
- C. Avoid cigarette smoking.
- D. Avoid caffeinated beverages.
- E. Eat small meals and snacks high in calories.
- F. Eat high-fat, low-protein, high-carbohydrate meals.
Correct Answer: A,B,C,D,E
Rationale: Chronic pancreatitis is a progressive, destructive disease of the pancreas, characterized by remissions and exacerbations (recurrence). Measures to prevent an exacerbation include eating bland, low-fat, high-protein, moderate-carbohydrate meals; avoiding alcohol ingestion, nicotine, and caffeinated beverages; eating small meals and snacks high in calories; and avoiding gastric stimulants such as spices.
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
The nurse provides information to a client with a colostomy. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
- A. Parsley
- B. Yogurt
- C. Buttermilk
- D. Cucumbers
- E. Cauliflower
- F. Cranberry juice
Correct Answer: A,B,C,F
Rationale: The nurse should provide information about foods and measures that will prevent odor from a colostomy. Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Foods that cause flatus and thus odor, including broccoli, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should be avoided.
The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet?
- A. Spinach
- B. Custard
- C. Scrambled eggs
- D. Mashed potatoes
Correct Answer: A
Rationale: Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.
A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement?
- A. Maintaining an intravenous access
- B. Ensuring that oxygen is being delivered
- C. Administering sedation to prevent claustrophobia
- D. Providing emotional support to the client's family
Correct Answer: B
Rationale: Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.