Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following complications?
- A. Hypercapnia.
- B. Hypotension.
- C. Pulmonary edema.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: Clients with COPD are at risk for hypercapnia (elevated CO2 levels) during pneumonia due to impaired gas exchange, which can worsen respiratory distress.
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Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
- A. Remove the tube.
- B. Deflate the esophageal portion of the tube.
- C. Determine whether the tube is obstructing the airway.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.
The nurse is caring for a client with a history of benign prostatic hypertrophy who is prescribed finasteride (Proscar). The nurse should instruct the client that this medication works by:
- A. Relaxing bladder muscles.
- B. Reducing prostate size.
- C. Increasing urine flow.
- D. Preventing urinary infections.
Correct Answer: B
Rationale: Finasteride reduces prostate size by inhibiting testosterone conversion, relieving urinary obstruction in BPH.
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician orders 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
- A. Crackles in the lung bases.
- B. Blood pressure elevation.
- C. Cerebral edema.
- D. Cool skin temperature in lower extremities.
Correct Answer: B
Rationale: Albumin increases oncotic pressure, pulling fluid into the vascular space, which may elevate blood pressure. Crackles, cerebral edema, or cool extremities would indicate complications.
The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
- A. Remove the IV catheter.
- B. Document the occurrence.
- C. Stop the blood transfusion.
- D. Contact the primary health care provider.
- E. Hang 0.9% sodium chloride solution.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response. To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.
A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for:
- A. Irritability.
- B. Hyperventilation.
- C. Diarrhea.
- D. Edema.
Correct Answer: B
Rationale: Persistent vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, which can manifest as hyperventilation as the body compensates for elevated pH.