Nokea
A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client?
- A. Nasal cannula
- B. Non-rebreathing mask
- C. Oxymizer
- D. Venturi mask
Correct Answer: D
Rationale: A Venturi mask (D) delivers precise oxygen concentrations, ideal for COPD exacerbation to avoid hypercapnia. Nasal cannula (A), non-rebreathing mask (B), and Oxymizer (C) are less precise.
You may also like to solve these questions
The nurse should consider which of the following client reports as an indication of an allergic reaction?
- A. I can't eat broccoli or cabbage when I take my warfarin.'
- B. I get a headache when using my nitroglycerine patch.'
- C. My feet swell when I take felodipine.'
- D. My lips swell when I eat bananas or avocados.'
Correct Answer: D
Rationale: Lip swelling (D) indicates an allergic reaction to food. Broccoli/cabbage (A) affects warfarin's efficacy, headaches (B) are a side effect of nitroglycerin, and swelling (C) is a side effect of felodipine.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?
- A. Check for a history of bipolar disease
- B. Determine if restraints can now be removed
- C. Monitor for ECG changes
- D. Obtain blood for the current blood alcohol level
Correct Answer: B
Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (B) is the priority to minimize harm and promote safety. Bipolar history (A), ECG changes (C), and blood alcohol level (D) are important but less urgent.