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A client with chronic obstructive pulmonary disease (COPD) is prescribed long-term oxygen therapy. What is the most important nursing consideration for this client?
- A. Assessing for signs of oxygen toxicity
- B. Monitoring the client's carbon dioxide levels
- C. Promoting proper humidification of oxygen
- D. Ensuring an adequate supply of oxygen
Correct Answer: B
Rationale: Monitoring carbon dioxide levels (B) is critical in COPD clients on long-term oxygen therapy, as they may retain CO2, risking respiratory acidosis if oxygen suppresses their hypoxic drive (target SpO2 88-92%). Oxygen toxicity (A) is rare at low flows used in COPD. Humidification (C) enhances comfort but isn't the priority. Oxygen supply (D) is a general need, not COPD-specific. CO2 monitoring via ABGs or capnography ensures safe titration, preventing hypercapnia, a key consideration per COPD management guidelines like GOLD standards.
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The nurse is aware that the normal frequency of bowel sounds is
- A. 1-5 gurgles/minute
- B. 5-35 gurgles/minute
- C. 35-60 gurgles/minute
- D. 60-100 gurgles/minute
Correct Answer: B
Rationale: Normal bowel sounds are 5-35 gurgles/minute e.g., peristalsis per norms. Less (hypoactive), more (hyperactive) differ. Nurses count e.g., 1 minute for function, per standards.
When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
- A. The goal of reducing john's fever has been met with full satisfaction of the outcome criteria
- B. The desired goal has been partially met
- C. The goal is not completely met
- D. The goal has been met but not with the desired outcome criteria
Correct Answer: A
Rationale: Paracetamol dropping fever from 40°C to 36.7°C in 10 minutes fully meets the goal of fever reduction e.g., normal range (36.6-38°C) achieved. Partial or unmet goals imply residual fever; undesired criteria suggest side effects (none here). Nurses document this success, per outcome evaluation standards.
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: Hematocrit (HCT) 70% e.g., polycythemia can raise BP (viscosity) or lower it (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises BP). Nurses assess this e.g., in anemia for variable impacts, per circulatory dynamics.
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.