Nokea
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
- A. Reposition the nasal cannula
- B. Lower the oxygen rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Lower the oxygen rate. Increasing oxygen flow too quickly can lead to oxygen toxicity in COPD patients, causing symptoms like lethargy and confusion. Lowering the oxygen rate will help alleviate the symptoms and prevent further harm. Repositioning the nasal cannula (choice A) is not the priority in this situation. Encouraging coughing and deep breathing (choice C) may not address the immediate issue of oxygen toxicity. Monitoring oxygen saturation (choice D) is important but should follow lowering the oxygen rate to address the current symptoms.
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The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
- A. Monitor serum calcium levels
- B. Obtain a baseline electrocardiogram
- C. Implement seizure precautions
- D. Encourage a low-protein diet
Correct Answer: C
Rationale: The correct answer is C. Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.
The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
- A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
- B. Take vitamin K 10mg PO daily to enhance production of red blood cells
- C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
- D. Combine several legumes and grains such as beans and rice to form complete proteins
Correct Answer: D
Rationale: The correct answer is D: Combine several legumes and grains such as beans and rice to form complete proteins. This is the best option because a lacto-vegetarian diet excludes meat but includes dairy products. Legumes and grains complement each other in terms of amino acid profiles, allowing the individual to obtain all essential amino acids needed for protein synthesis. This combination ensures the client gets adequate protein intake necessary for red blood cell production without consuming meat.
A: Drinking whole milk instead of skim milk does not enhance amino acid production. Skim milk contains the same amino acids as whole milk.
B: Taking vitamin K does not enhance red blood cell production. Iron is the key nutrient needed for red blood cell production.
C: Increasing dark yellow vegetables such as carrots does not provide a significant amount of iron to fortify iron stores compared to legumes and grains.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
- A. Cleanse the perineum with warm soapy water 3 times per day
- B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
- C. Perform a glucose measurement using a capillary blood sample
- D. Obtain a blood specimen for sexually transmitted diseases (STDs)
Correct Answer: B
Rationale: The correct answer is B: Instill the first dose of nystatin (Mycostatin) vaginally per applicator. This is the appropriate action for a college student with symptoms of a vaginal infection with a 'cottage cheese' appearance discharge, which is indicative of a yeast infection (most likely caused by Candida). Nystatin is an antifungal medication effective against Candida, hence addressing the root cause of the infection. It is essential to start with the treatment first to alleviate the symptoms and prevent further complications.
Incorrect choices:
A: Cleansing the perineum with warm soapy water may provide some comfort but does not address the underlying infection.
C: Performing a glucose measurement is not necessary at this stage as the symptoms suggest a yeast infection, not diabetes.
D: Obtaining a blood specimen for STDs is not the priority in this case as the symptoms are indicative of a yeast infection, not an STD.
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
- A. Daily intake and output
- B. Skin turgor
- C. Daily weight
- D. Vital signs every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.
Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.
Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.
Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.