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A client who has a history of unstable angina is admitted to the emergency department with chest pain.
- A. Chest pain relieved by rest.
- B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
- C. Chest pain occurring only with exertion.
- D. Chest pain lasting less than 5 minutes.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?
- A. Increased respiratory rate
- B. Decreased level of consciousness
- C. Improved oxygen saturation
- D. Complaints of dry mouth
Correct Answer: B
Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.
Which nursing problem has the highest priority when planning care for a client with Meniere's disease?
- A. Potential for injury related to vertigo.
- B. Alteration in comfort due to ear pain.
- C. Impaired skin integrity due to immobility.
- D. Anxiety due to fear of falling.
Correct Answer: A
Rationale: The correct answer is A. When caring for a client with Meniere's disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere's disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.
A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct Answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.
A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?
- A. Reinforce the incisional dressings and assess behind the neck for drainage.
- B. Place the client in a right lateral side-lying position and elevate the head of the bed.
- C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.
- D. Compress the bulb with the tab open and then reinsert the tab into its opening.
Correct Answer: D
Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.
An 82-year-old female client with type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. What should the nurse recommend?
- A. Seek routine nail care with a podiatrist.
- B. Encourage monthly pedicures at a nail salon.
- C. Soak feet for 10 minutes before cutting nails.
- D. Ask a family member to cut toenails.
Correct Answer: A
Rationale: For an 82-year-old female client with type 2 diabetes and degenerative arthritis, the nurse should recommend seeking routine nail care with a podiatrist. This is crucial to ensure proper and safe toenail care, reducing the risk of injury and infection, which is especially important for diabetic clients. Encouraging monthly pedicures at a nail salon (choice B) may not address the underlying issues related to diabetes and arthritis. Soaking feet for 10 minutes before cutting nails (choice C) may help soften the nails but does not address the difficulty the client faces in cutting them. Asking a family member to cut toenails (choice D) may not guarantee the expertise needed for proper diabetic foot care, which a podiatrist can provide.