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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 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.
For a patient with asthma, what is the primary purpose of prescribing montelukast?
- A. Relieve acute bronchospasm
- B. Prevent asthma attacks
- C. Thin respiratory secretions
- D. Suppress cough
Correct Answer: B
Rationale: The primary purpose of prescribing montelukast for a patient with asthma is to prevent asthma attacks. Montelukast is a leukotriene receptor antagonist that helps to reduce inflammation in the airways, thereby preventing asthma symptoms and attacks. It is not used to relieve acute bronchospasm (Choice A), as it is not a fast-acting rescue medication like a bronchodilator. Montelukast also does not thin respiratory secretions (Choice C) or suppress cough (Choice D) as its main mechanism of action is to prevent and control asthma symptoms by inhibiting leukotrienes.
A patient with schizophrenia is prescribed olanzapine. What is an important side effect for the healthcare provider to monitor?
- A. Hypertension
- B. Weight gain
- C. Hypoglycemia
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine is known to cause metabolic side effects, including weight gain. This is important to monitor as it can lead to various health issues such as diabetes and cardiovascular problems. Hypertension (A), hypoglycemia (C), and bradycardia (D) are not commonly associated with olanzapine use, making them less likely side effects to monitor in this case.
The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant receive?
- A. 9 mg
- B. 18 mg
- C. 27 mg
- D. 36 mg
Correct Answer: A
Rationale: To calculate the dose of Streptomycin, we first need to convert the infant's weight from pounds to kg (4 lbs = 1.81 kg). Then, we multiply the weight in kg by the prescribed dose (15 mg/kg) to get the total dose (1.81 kg * 15 mg/kg = 27.15 mg). Since the drug is diluted in 25 ml of D5W, the infant will receive 27.15 mg in 25 ml solution. To find how much Streptomycin the infant actually receives, we need to calculate the amount in 1 ml (27.15 mg / 25 ml = 1.086 mg/ml). Finally, to determine how much the infant will receive over 8 hours, we multiply the concentration by the infusion rate (1.086 mg/ml * 25 ml * 8 hours = 217.2 mg). Therefore, the correct answer is A: 9 mg, as it represents the amount
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
- A. Palpate for the presence of femoral pulses bilaterally.
- B. Assess for the presence of a positive Homan's sign.
- C. Observe the appearance of the skin on the client's legs.
- D. Watch the client's posture and balance during ambulation.
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth.
Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.