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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct Answer: C
Rationale: The correct answer is C: Check the client's oxygen saturation level. This is the first action the nurse should take to assess the effectiveness of the current oxygen therapy and determine the client's oxygenation status. A: Increasing the oxygen flow rate without assessing the client's oxygen saturation level may lead to potential oxygen toxicity. B: Instructing the client to breathe deeply and cough may not address the underlying issue of hypoxemia. D: Placing the client in a high-Fowler's position may help with breathing but does not address the immediate concern of the client's difficulty breathing. Checking the oxygen saturation level provides crucial information for appropriate interventions.
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The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
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 client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress.
A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath.
B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath.
C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct Answer: A
Rationale: The correct answer is A: Blow cool air from a hair dryer under the cast. This method helps to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective.
Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm.
Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection.
Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.
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.