Nokea
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?
- A. Administer oxygen therapy
- B. Encourage the client to perform deep breathing exercises
- C. Raise the head of the bed
- D. Check the client's oxygen saturation level
Correct Answer: D
Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.
You may also like to solve these questions
The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?
- A. I will monitor my blood glucose levels regularly and keep a record to show my healthcare provider.
- B. I will follow my meal plan and exercise regularly to help manage my blood sugar levels.
- C. I will stop taking my medications if my blood sugar levels are normal.
- D. I will continue to take my medications even if I feel better.
Correct Answer: C
Rationale: Choice C indicates a need for further teaching because stopping medications when blood sugar levels are normal can lead to uncontrolled blood sugar levels if the individual does not understand the importance of medication adherence in managing diabetes. Choices A, B, and D are correct statements that demonstrate good understanding of managing diabetes, such as monitoring blood glucose levels, following a meal plan, exercising regularly, and adhering to medication even when feeling better.
The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID
- A. Glycerin suppositories
- B. Fiber supplements
- C. Laxatives
- D. Stool softeners
Correct Answer: C
Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.
To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct Answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.
An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?
- A. Assess the severity and location of the pain
- B. Obtain an order for an analgesic
- C. Reassure the client that this is not unusual for his age
- D. Encourage the client to increase activity
Correct Answer: A
Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.
A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?
- A. Auscultation of breath sounds
- B. Measurement of peak expiratory flow
- C. Observation of the client's use of accessory muscles
- D. Assessment of the client's skin color
Correct Answer: A
Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.