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A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?
- A. Administer bronchodilators as prescribed.
- B. Administer oxygen via nasal cannula.
- C. Encourage the client to cough and deep breathe.
- D. Position the client in high Fowler's position.
Correct Answer: B
Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.
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The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?
- A. Check the drainage tubing for a kink
- B. Review the intake and output record
- C. Notify the healthcare provider
- D. Give the client 8 oz of water to drink
Correct Answer: A
Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.
A client with chronic renal failure is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?
- A. White blood cell count.
- B. Hemoglobin and hematocrit.
- C. Platelet count.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct Answer: B
Rationale: The correct answer is B: Hemoglobin and hematocrit. These are the primary laboratory tests to monitor the effectiveness of epoetin alfa (Epogen) in treating anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not directly related to the effects of this medication. Epoetin alfa stimulates the production of red blood cells, so monitoring hemoglobin and hematocrit levels helps assess the response to the treatment.
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?
- A. Agree with the client until they are ready to accept the colostomy.
- B. Say 'It must be difficult to have this kind of surgery'.
- C. Force the client to look at their colostomy.
- D. Ask the surgeon to explain the surgery to the client.
Correct Answer: B
Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?
- A. Record the coughing incident. No further action is required at this time.
- B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
- C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
- D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct Answer: C
Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes. The nurse should assess tube placement in this way before taking any other action to ensure the tube is still in the correct position and prevent potential complications. Choice A is incorrect because further assessment is needed due to the risk of tube displacement. Choice B is incorrect as stopping the feeding and involving the family is premature without confirming tube placement. Choice D is incorrect as injecting air and auscultating for gurgling is not the recommended method to confirm tube placement.