Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Administer a bronchodilator as ordered.
- C. Place the client in a high Fowler’s position.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: C
Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment
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Which play activity is best suited to the gross motor skills of the toddler?
- A. Coloring book and crayons
- B. Ball
- C. Building cubes
- D. Swing set
Correct Answer: B
Rationale: Playing with a ball encourages gross motor skills like kicking and throwing, suitable for a toddler's developmental stage.
Which statement is incorrect regarding the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987 (OBRA '87)?
- A. the right to be free of unnecessary chemical restraints
- B. the right to choose a personal physician
- C. the right to access medical records
- D. the right to organize hospital personnel within a union
Correct Answer: D
Rationale: OBRA '87 does not include the right to organize hospital personnel into a union. Other rights are part of the act.
A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?
- A. Hgb level increase from 8.9 to 10.6
- B. Temperature reading of 99.4°F
- C. White blood cell count of 11,000
- D. Decrease in oozing of blood from IV site
Correct Answer: D
Rationale: Platelet infusions aim to improve clotting. Decreased oozing from an IV site indicates effective platelet function. The other findings are unrelated to platelets.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
- A. The baby is sleeping.
- B. The umbilical cord is compressed.
- C. There is head compression.
- D. There is uteroplacental insufficiency.
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.
The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
- A. allergic contact dermatitis.
- B. Crohn's disease.
- C. graft versus host disease.
- D. penicillin allergy.
Correct Answer: D
Rationale: Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).