Nokea
A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L per minute. The nurse assesses the client's respiratory rate at 22 breaths per minute. When the client reports an increase in the dyspnea, what should the nurse do initially?
- A. Determine the need to increase the oxygen.
- B. Call emergency services to come to the home.
- C. Reassure the client that there is no need to worry.
- D. Collect more information about the client's respiratory status.
Correct Answer: D
Rationale: Completing an assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the primary health care provider, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry.
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A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Take the medication with meals.
- C. Avoid using the inhaler during an acute attack.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after ipratropium inhalation prevents oral irritation or infection.
A client with a history of migraines is prescribed sumatriptan (Imitrex). The nurse should instruct the client to take the medication:
- A. Daily to prevent migraines.
- B. At the onset of a migraine.
- C. With meals to enhance absorption.
- D. At bedtime to reduce side effects.
Correct Answer: B
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the headache.
A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms and the patient was a secret agent to the medication and the medication days ago because it was no longer helping him, but now he feels terrible. The nurse should assess the client for which of the following? Select all that apply.
- A. Insomnia.
- B. Euphoria.
- C. Bradycardia.
- D. Diaphoresis.
- E. Tremor.
- F. Vomiting.
Correct Answer: A, D, E, F
Rationale: Abrupt cessation of diazepam can cause withdrawal symptoms like insomnia, diaphoresis, tremor, and vomiting.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dofetilide (Tikosyn). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Torsades de pointes.
- D. Weight gain.
Correct Answer: C
Rationale: Dofetilide can cause torsades de pointes, a life-threatening arrhythmia, requiring close monitoring.
The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.