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A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated
- B. Avoid wearing oxygen during physical activity
- C. Do not smoke while using oxygen
- D. Store oxygen tanks in a cool, dark place
Correct Answer: C
Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.
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A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?
- A. Check the client's respiratory rate
- B. Assess the client's pain level
- C. Monitor the client's blood pressure
- D. Evaluate the client's level of consciousness
Correct Answer: A
Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.
A client is admitted with diabetic ketoacidosis. What is the most critical treatment to initiate?
- A. Administer sodium bicarbonate IV
- B. Start an insulin drip
- C. Monitor glucose and ketone levels
- D. Provide oral hydration
Correct Answer: B
Rationale: In the case of diabetic ketoacidosis, the most critical treatment to initiate is starting an insulin drip. Insulin therapy is crucial for reducing blood glucose levels by promoting glucose uptake in cells and inhibiting the production of ketones. Administering sodium bicarbonate IV is generally not recommended as it may lower the pH further and potentially worsen the condition. While monitoring glucose and ketone levels is important for assessing the response to treatment, initiating insulin therapy takes precedence. Providing oral hydration alone is insufficient to manage the metabolic derangements seen in diabetic ketoacidosis.
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
- A. Administer bronchodilator therapy as prescribed
- B. Encourage deep breathing and coughing exercises
- C. Position the client in a high-Fowler's position
- D. Increase the oxygen flow rate
Correct Answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.
The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?
- A. Increase potassium-rich foods in the diet
- B. Avoid foods high in sodium
- C. Monitor fluid intake and adjust as needed
- D. Take the medication in the morning
Correct Answer: A
Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.
A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?
- A. Encourage mobilization and ambulation
- B. Encourage energy conservation with complete bed rest
- C. Provide humidified oxygen via nasal cannula
- D. Restrict oral (PO) and intravenous fluids
Correct Answer: A
Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.