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A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which clinical finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C. The use of accessory muscles in a client with COPD indicates increased work of breathing and may signal respiratory failure, requiring immediate intervention. This finding suggests that the patient is struggling to breathe effectively. Oxygen saturation of 90% is low but not critically low, while a respiratory rate of 24 breaths per minute is slightly elevated but not as concerning as the increased work of breathing indicated by the use of accessory muscles. Inspiratory crackles may be present in COPD due to underlying conditions like pneumonia but do not require immediate intervention as the use of accessory muscles does.
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Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?
- A. The one with the clamp and no needle
- B. A butterfly needle
- C. A non-coring (Huber) needle
- D. A standard hypodermic needle
Correct Answer: C
Rationale: The correct needle to use for administering intravenous fluids via an implanted port is a non-coring (Huber) needle. This type of needle is specifically designed to access implanted ports without coring the septum, which helps prevent damage. Choice A, the one with the clamp and no needle, is incorrect as it does not describe a needle suitable for accessing an implanted port. Choice B, a butterfly needle, is not typically used for accessing implanted ports. Choice D, a standard hypodermic needle, is not ideal for accessing ports as it can damage the septum.
A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?
- A. Peripheral edema
- B. Increased abdominal girth
- C. Confusion and altered mental status
- D. Yellowing of the skin
Correct Answer: C
Rationale: The correct answer is C. Confusion and altered mental status are the most concerning clinical findings in a client with cirrhosis because they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Peripheral edema (choice A) and increased abdominal girth (choice B) are common manifestations of cirrhosis but are not as acutely concerning as signs of hepatic encephalopathy. Yellowing of the skin (choice D) is due to jaundice, which is already present in the client and does not directly indicate a worsening condition like confusion and altered mental status.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning to the nurse?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Respiratory rate of 28 breaths per minute
Correct Answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and indicates hypoxemia, requiring immediate intervention. In COPD, the body's ability to oxygenate adequately is already compromised, so a saturation of 85% is particularly concerning. A barrel-shaped chest and use of accessory muscles are common findings in COPD due to chronic air trapping and increased work of breathing. While a respiratory rate of 28 breaths per minute is elevated, a low oxygen saturation is a more critical finding that necessitates prompt attention.
A client with chronic liver disease is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Enlarged spleen
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Confusion and altered mental status
Correct Answer: D
Rationale: Confusion and altered mental status are concerning in a client with chronic liver disease, as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Enlarged spleen (choice A) can be a common finding in liver disease due to portal hypertension but may not be as acute as hepatic encephalopathy. Increased abdominal girth (choice B) is typically seen in ascites, which is already present in this client. Yellowing of the skin (choice C) is a manifestation of jaundice, also a known symptom in liver disease but not as acute as confusion and altered mental status.
A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?
- A. Rented movies and borrowed books to use while passing time at home
- B. Made an appointment with the oncologist for follow-up treatment
- C. Expressed concern about hair loss and fatigue
- D. Asked for dietary recommendations to manage nausea
Correct Answer: A
Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.