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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.
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The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish colored amniotic fluid. The nurse interprets this finding as related to which of the following?
- A. Passage of meconium by the fetus.
- B. Maternal intrauterine infection.
- C. Rh incompatibility between mother and fetus.
- D. Maternal sexually transmitted disease.
Correct Answer: A
Rationale: Greenish amniotic fluid indicates meconium passage, often due to fetal stress.
A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse include?
- A. Strategies to manage memory loss and confusion.
- B. Instructions to limit physical activity to prevent falls.
- C. The need for a low-protein diet to reduce metabolic stress.
- D. The importance of avoiding all medications that affect the brain.
Correct Answer: A
Rationale: Multi-infarct dementia involves memory loss and confusion due to multiple small strokes. Teaching strategies to manage these symptoms, such as memory aids and structured routines, is essential for supporting the client and family.
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.
A client with a history of heart failure is admitted with jugular vein distension. The nurse should include which of the following in the plan of care?
- A. Administer furosemide as prescribed.
- B. Position the client in Fowler's position.
- C. Restrict sodium intake.
- D. Encourage ambulation.
Correct Answer: A, B, C
Rationale: Furosemide, Fowler's position, and sodium restriction reduce fluid overload in heart failure.
A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.