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A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Barrel-shaped chest.
- B. Use of accessory muscles to breathe.
- C. Oxygen saturation of 88%.
- D. Respiratory rate of 22 breaths per minute.
Correct Answer: C
Rationale: The correct answer is C: Oxygen saturation of 88%. In COPD patients, low oxygen saturation indicates inadequate gas exchange and potential respiratory distress. Oxygen saturation below 90% requires immediate intervention to prevent hypoxemia. A: Barrel-shaped chest is a common finding in COPD due to hyperinflation, but it is not a critical indicator of acute exacerbation. B: Use of accessory muscles suggests increased work of breathing but may not be as urgent as low oxygen saturation. D: Respiratory rate is within normal range, so it is less concerning than the low oxygen saturation.
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A patient with peptic ulcer disease is prescribed omeprazole. When should the patient take this medication for optimal effectiveness?
- A. With meals
- B. At bedtime
- C. Before meals
- D. After meals
Correct Answer: C
Rationale: The correct answer is C: Before meals. Omeprazole is a proton pump inhibitor that works best when taken before meals to inhibit acid secretion before food intake. Taking it with meals (choice A) may decrease its effectiveness as it needs time to be absorbed. Taking it at bedtime (choice B) may not provide optimal coverage throughout the day. Taking it after meals (choice D) may not allow enough time for the medication to start working before the next meal.
A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?
- A. You are lucky to be alive. Be grateful no one was killed.'
- B. I understand your car was not seriously damaged.'
- C. You are upset that this incident has brought you here.'
- D. Have you ever been in the emergency department before?'
Correct Answer: C
Rationale: The correct answer is C: "You are upset that this incident has brought you here." This response acknowledges the client's feelings of anger and validates her emotions, showing empathy and understanding. It demonstrates active listening and therapeutic communication, which is crucial in building trust and rapport with the client.
Choice A is incorrect as it dismisses the client's feelings of anger and invalidates her emotions by shifting the focus to being grateful instead. Choice B is incorrect as it minimizes the client's emotional response by focusing on the material aspect of the situation rather than addressing her feelings. Choice D is incorrect as it does not address the client's emotional state and is a closed-ended question that does not encourage further discussion or exploration of the client's feelings.
After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?
- A. Pedal pulses.
- B. Breath sounds.
- C. Gag reflex.
- D. Vital signs.
Correct Answer: D
Rationale: The correct answer is D: Vital signs. After paracentesis, monitoring vital signs is crucial as fluid removal can lead to changes in blood pressure, heart rate, and overall fluid balance. Hypotension or tachycardia may indicate hypovolemia or shock. Pedal pulses (A) are important but not as critical post-paracentesis. Breath sounds (B) are important for respiratory assessment but not directly related to fluid removal. Gag reflex (C) is unrelated to paracentesis and not a priority post-procedure.
A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Bowel sounds active in all quadrants.
- B. Blood pressure of 110/70 mm Hg.
- C. Rigid, board-like abdomen.
- D. Heart rate of 90 beats per minute.
Correct Answer: C
Rationale: The correct answer is C: Rigid, board-like abdomen. This finding suggests peritonitis, a serious complication of peptic ulcer disease, requiring immediate medical intervention. A: Active bowel sounds are expected. B: Blood pressure is within normal range. D: Heart rate is slightly elevated but not a critical finding. In summary, a rigid abdomen indicates peritonitis and requires urgent attention compared to the other choices.
A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct Answer: D
Rationale: The correct answer is D: No palpable pulse. Ventricular fibrillation is a life-threatening arrhythmia where the heart quivers and doesn't effectively pump blood. This results in the absence of a palpable pulse. The nurse should anticipate this finding as it indicates a severe cardiac emergency requiring immediate intervention. Choices A, B, and C are incorrect because ventricular fibrillation leads to ineffective heart contractions, causing a lack of pulse rather than bounding, irregular, or thready pulses. It is crucial for the nurse to recognize the absence of a palpable pulse to initiate prompt resuscitative measures.