Nokea
A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Elevate the head of the bed.
- C. Obtain a sputum culture.
- D. Administer antibiotics as prescribed.
Correct Answer: A
Rationale: In a client with COPD admitted with pneumonia, the priority intervention should be to administer oxygen therapy as prescribed. This is crucial to improve oxygenation, especially in a client with compromised respiratory function. Elevating the head of the bed can help with breathing but is secondary to ensuring adequate oxygenation. Obtaining a sputum culture and administering antibiotics are important steps in the treatment of pneumonia but come after ensuring adequate oxygen supply.
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A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?
- A. White blood cell count of 2,000/mm³
- B. Platelet count of 100,000/mm³
- C. Hemoglobin level of 10 g/dL
- D. Serum creatinine level of 1.5 mg/dL
Correct Answer: A
Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.
A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?
- A. Oatmeal cookies
- B. Cheese sticks
- C. Yogurt
- D. Apple slices
Correct Answer: A
Rationale: Oatmeal cookies are the best snack suggestion for a preschooler with constipation needing to increase fiber intake. Oatmeal is high in fiber, which helps relieve constipation. Cheese sticks, yogurt, and apple slices are not as high in fiber content as oatmeal and may not be as effective in addressing the constipation issue in this scenario.
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?
- A. Decreased abdominal girth
- B. Increased blood pressure
- C. Clear breath sounds
- D. Decreased serum albumin
Correct Answer: A
Rationale: The correct answer is A: Decreased abdominal girth. In a client with cirrhosis of the liver, a LeVeen shunt is used to treat ascites, which is the accumulation of fluid in the peritoneal cavity. A decrease in abdominal girth indicates that the shunt is effectively draining the ascitic fluid, relieving the client's abdominal distension. Choice B, increased blood pressure, is incorrect as a LeVeen shunt is not expected to impact blood pressure. Choice C, clear breath sounds, is unrelated to the effectiveness of a LeVeen shunt in managing ascites. Choice D, decreased serum albumin, is also not a direct indicator of the shunt's effectiveness in draining ascitic fluid.
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Administer anti-inflammatory medication before the procedure.
- C. Encourage the client to perform range-of-motion exercises.
- D. Reschedule the procedure for later in the day.
Correct Answer: A
Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.
The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can increase red blood cell production, leading to a higher demand for potassium. Monitoring potassium levels is crucial to prevent hyperkalemia, a potential risk associated with this therapy. Hemoglobin level (Choice B) is important to assess the effectiveness of erythropoietin therapy, but monitoring potassium levels takes precedence due to the risk of hyperkalemia. White blood cell count (Choice C) and serum calcium level (Choice D) are not directly affected by erythropoietin therapy in the context of chronic kidney disease.