Nokea
A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Increased abdominal girth
Correct Answer: B
Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.
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A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?
- A. 2 liters per minute
- B. 4 liters per minute
- C. 6 liters per minute
- D. 8 liters per minute
Correct Answer: B
Rationale: The correct answer is 4 liters per minute. Without a healthcare provider's order, the nurse should administer a maximum of 4 liters per minute of oxygen to prevent carbon dioxide retention in COPD clients. Higher flow rates can lead to oxygen toxicity and worsen the client's condition. Choices A, C, and D exceed the safe limit for oxygen administration without a healthcare provider's order.
A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Instruct the client to rest until the oxygen saturation improves.
- C. Discontinue ambulation and return the client to bed.
- D. Encourage the client to breathe more deeply.
Correct Answer: C
Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 94%
- C. Carbon dioxide level of 45 mmHg
- D. Respiratory rate of 20 breaths per minute
Correct Answer: C
Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.
A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Severe abdominal distention
- B. Decreased urine output
- C. Decreased bowel sounds
- D. Increased heart rate
Correct Answer: A
Rationale: Severe abdominal distention is a sign of worsening pancreatitis and can indicate complications like bowel obstruction or fluid accumulation. Immediate intervention is necessary to prevent further deterioration. Decreased urine output (Choice B) could indicate renal impairment, decreased bowel sounds (Choice C) are expected in pancreatitis due to paralytic ileus, and an increased heart rate (Choice D) is a common response to pain or stress in acute pancreatitis but may not require immediate intervention unless it is extremely high or persistent.
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
- A. Stroke the inner thigh below the perineum to initiate urinary flow
- B. Contract, hold, and then relax the pubococcygeal muscle
- C. Pour warm water over the external sphincter at the distal glans
- D. Apply downward manual pressure at the suprapubic regions
Correct Answer: D
Rationale: The client is applying pressure in the wrong region (umbilical area) and should be instructed to apply pressure at the suprapubic area. Applying downward manual pressure at the suprapubic region helps in emptying the bladder effectively by assisting in pushing the urine out through the urethra. Choices A, B, and C are incorrect because they do not address the specific issue of applying pressure to help empty the bladder using the Crede Method.