Nokea
A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
- A. Productive cough with yellow sputum.
- B. Oxygen saturation of 88%.
- C. Respiratory rate of 20 breaths per minute.
- D. Heart rate of 90 beats per minute.
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.
You may also like to solve these questions
A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?
- A. Encourage the client to ignore the voices and stay focused on reality.
- B. Acknowledge the client's feelings and ask what the voices are saying.
- C. Redirect the conversation to help distract the client from the hallucinations.
- D. Offer reassurance that the voices cannot harm the client.
Correct Answer: B
Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units have you worked on?
- B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.
The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct Answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
A client with gastroesophageal reflux disease (GERD) is prescribed omeprazole. What is the primary purpose of this medication?
- A. Coat the lining of the stomach
- B. Neutralize stomach acid
- C. Promote gastric motility
- D. Reduce gastric acid secretion
Correct Answer: D
Rationale: The correct answer is D: Reduce gastric acid secretion. Omeprazole is a proton pump inhibitor that works by reducing the production of gastric acid in the stomach. This helps in managing GERD by decreasing the acidity levels in the stomach. Choice A is incorrect because omeprazole does not coat the lining of the stomach. Choice B is incorrect as omeprazole does not neutralize stomach acid but rather reduces its production. Choice C is incorrect because omeprazole does not promote gastric motility; instead, it acts on acid secretion.
The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
- A. Question the client about the frequency of falls.
- B. Request the client to lie still during the assessment.
- C. Ask how often episodes of sundowning are experienced.
- D. Assist the client with values clarification about end-of-life care.
Correct Answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.