Nokea
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:
- A. Be drying to nasal passages
- B. Decrease the client's oxygen-based respiratory drive
- C. Increase the risk of pneumonia due to drier air passages
- D. Decrease the client's carbon dioxide-based respiratory drive
Correct Answer: B
Rationale: Increasing the oxygen flow rate beyond 2 L/min for a client with COPD can decrease the client's oxygen-based respiratory drive. In clients with COPD, the natural respiratory drive is based on the level of oxygen instead of carbon dioxide, as seen in healthy individuals. Increasing the oxygen level independently can suppress the drive to breathe, leading to respiratory failure. Choices A, C, and D are incorrect because drying of nasal passages, increased risk of pneumonia due to drier air passages, and decreasing the carbon dioxide-based respiratory drive are not the primary concerns associated with increasing the oxygen flow rate in a client with COPD.
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A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action?
- A. Calculate the mean arterial pressure (MAP).
- B. Ask for insertion of a pulmonary artery catheter.
- C. Take the client's pulse.
- D. Slow down the normal saline infusion.
Correct Answer: D
Rationale: The nurse should recognize that the client may be developing fluid overload and respiratory distress due to the rapid normal saline infusion. The priority action is to slow down the infusion to prevent worsening respiratory distress and potential fluid overload. While calculating the mean arterial pressure (MAP) is important to assess perfusion, addressing the immediate respiratory distress takes precedence. Inserting a pulmonary artery catheter would provide detailed hemodynamic information but is not the initial step in managing acute respiratory distress. Monitoring vital signs, including the client's pulse, is crucial after adjusting the intravenous infusion to ensure a safe response to the intervention.
A client is starting urinary bladder training. Which statement should the nurse include in this client's teaching?
- A. Use the toilet when you first feel the urge, rather than at specific intervals.
- B. Try to consciously hold your urine until the scheduled toileting time.
- C. Initially try to use the toilet at least every half hour for the first 24 hours.
- D. The toileting interval can be increased once you have been continent for a week.
Correct Answer: B
Rationale: In urinary bladder training, the client should be taught to try to consciously hold their urine until the scheduled toileting time. This helps in training the bladder to hold urine for longer periods. Option A is incorrect because the goal is to consciously hold urine, not void immediately. Option C is incorrect as toileting at least every half hour may not promote bladder training. Option D is incorrect as increasing the toileting interval should be based on the client's comfort and progress, not just after being continent for a week.
A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?
- A. Infection
- B. Hypertension
- C. Low blood pressure
- D. Loss of cough reflex
Correct Answer: C
Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.
A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time?
- A. Decreased calcium levels
- B. Increased phosphorus levels
- C. No adventitious sounds in the lungs
- D. Increased edema in the legs
Correct Answer: C
Rationale: The absence of adventitious sounds upon auscultation of the lungs is a key indicator that the client's fluid balance is stable. Adventitious sounds, such as crackles or wheezes, are typically heard in conditions of fluid overload, indicating that the body is retaining excess fluid. Choices A and B, decreased calcium levels and increased phosphorus levels, are common laboratory findings associated with chronic kidney disease (CKD) and are not directly related to fluid balance. Increased edema in the legs is a sign of fluid imbalance, suggesting fluid retention in the tissues, which would not indicate stable fluid balance in a client with CKD on fluid restrictions.
The patient is being educated on taking hydrochlorothiazide. Which statement by the patient indicates a need for further teaching?
- A. I may need additional sodium and calcium while taking this medication.
- B. I should consume plenty of fruits and vegetables while taking this drug.
- C. I should be cautious when getting up from a bed or chair while on this medication.
- D. I will take the medication in the morning to reduce certain side effects.
Correct Answer: A
Rationale: The correct answer is A because patients do not require extra sodium or calcium while taking hydrochlorothiazide, a thiazide diuretic. This medication actually promotes the excretion of sodium and water. Choices B, C, and D are correct statements regarding the use of hydrochlorothiazide. Patients are encouraged to have a diet rich in fruits and vegetables, be careful with position changes due to potential orthostatic hypotension, and take the medication in the morning to reduce the need for frequent urination during nighttime.