Nokea
A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?
- A. Decreased white blood cell count
- B. Decreased respiratory rate
- C. Increased breath sounds
- D. Increased heart rate
Correct Answer: C
Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.
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A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?
- A. Blood glucose of 350 mg/dL
- B. Serum bicarbonate of 18 mEq/L
- C. Arterial pH of 7.20
- D. Serum potassium of 5.5 mEq/L
Correct Answer: C
Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.
A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Request a consultation with the ethics committee
- D. Ask the client's family to intervene
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.
The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?
- A. Hand rolls
- B. A trapeze bar
- C. A trochanter roll
- D. Hand-wrist splints
Correct Answer: C
Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.
A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
- A. We will determine who the durable power of attorney for health care form has designated.
- B. We will apply oxygen through a tube in your nose.
- C. We will ask if you have changed your mind.
- D. We will insert a breathing tube while we evaluate your condition.
Correct Answer: B
Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.
Before starting an intensive exercise program, what instruction is most important for the nurse to provide to the client?
- A. Be sure to have a complete physical examination before beginning your planned exercise program.
- B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
- C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
- D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Correct Answer: A
Rationale: Before starting an intensive exercise program, it is crucial for the client to have a complete physical examination. This examination ensures that the client is physically fit to engage in such activities and helps in identifying any underlying health issues that could be exacerbated by the exercise regimen. Choice B is incorrect because it focuses on stress levels related to eating habits rather than the importance of a physical examination for safety. Choice C is incorrect as exercise and stress management classes can complement each other rather than being mutually exclusive. Choice D is incorrect as monitoring weight loss, while important, is not as critical as ensuring the client's physical readiness for the exercise program.