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A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
- A. Encourage deep, rapid breathing during activity.
- B. Provide stimulation in the environment to maintain client alertness.
- C. Observe vital signs and oxygen saturation periodically during activity.
- D. Schedule activities before giving respiratory medications or treatments.
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.
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Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to maintain the patient's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's order is not a substitute for a client's consent to release medical information in the absence of a communicable disease.
- A. Report the disease to the public health agency while maintaining confidentiality.
- B. Share the information with the client's family.
- C. Obtain a physician's order to release information.
- D. Disclose the information to the client's employer.
Correct Answer: A
Rationale: Reporting STDs to public health agencies is mandatory, but confidentiality must be maintained except in specific legal circumstances.
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
- A. Your client may be experiencing a fluid overload.
- B. Your client may be experiencing an embolus.
- C. Your client may be hyperglycemic.
- D. Your client may have an inadvertent pneumothorax.
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
A client is prescribed lansoprazole for the chronic management of Zollinger-Ellison syndrome. The nurse determines that the client best understands this disorder and the medication regimen when the client reports taking which product for pain?
- A. Naprosyn
- B. Ibuprofen
- C. Acetaminophen
- D. Acetylsalicylic acid
Correct Answer: C
Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should take acetaminophen for pain relief. The client should not take medications that irritate the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (naprosyn and ibuprofen).
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.