Nokea
A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?
- A. Increase the client's oxygen to 6 liters/minute.
- B. Obtain a stat arterial blood gas.
- C. Lower the bed to a semi-Fowler's position.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: B
Rationale: A stat arterial blood gas evaluates oxygenation and ventilation, guiding treatment for acute dyspnea, prioritizing over oxygen adjustment or positioning.
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A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.
A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.
Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?
- A. Surgical consent form is not signed.
- B. Client's pulse oximeter reading is 96%.
- C. Preoperative chest x-ray report is not available.
- D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, risking cardiac arrhythmias during surgery, requiring immediate correction.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.