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A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?
- A. Oxygen saturation of 95%.
- B. Productive cough with clear sputum.
- C. Respiratory rate of 22/min.
- D. Client reports dyspnea.
Correct Answer: D
Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.
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A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 16/min.
- B. Blood pressure 118/78 mm Hg.
- C. Urinary output of 30 mL/hr.
- D. Absent deep-tendon reflexes.
Correct Answer: D
Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.
The healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
- A. Hyperthyroidism
- B. Thrombophlebitis
- C. Diverticulosis
- D. Hypocalcemia
Correct Answer: B
Rationale: Thrombophlebitis is a condition characterized by inflammation of a vein, which increases the risk of blood clots. The use of oral contraceptives further elevates the risk of clot formation, making them contraindicated in individuals with thrombophlebitis. Hyperthyroidism (Choice A), diverticulosis (Choice C), and hypocalcemia (Choice D) are not contraindications to the use of oral contraceptives.
A client who is at 10 weeks of gestation and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include?
- A. You should eat crackers before getting out of bed.
- B. You should drink ginger ale with your meals.
- C. You should lie down for 30 minutes after eating.
- D. You should avoid eating between meals.
Correct Answer: A
Rationale: The correct answer is A: 'You should eat crackers before getting out of bed.' Eating crackers before getting out of bed can help reduce nausea and vomiting during pregnancy. This recommendation helps in stabilizing blood sugar levels before fully waking up. Choice B is incorrect because ginger ale may exacerbate nausea due to its carbonation. Choice C is incorrect as lying down after eating can worsen symptoms of nausea. Choice D is incorrect as avoiding eating between meals can lead to low blood sugar levels, worsening nausea and vomiting.
A client is being taught about patient-controlled analgesia (PCA). Which statement should be included in the teaching?
- A. The PCA will deliver a double dose of medication when you push the button twice.
- B. Continuous PCA infusion is designed to allow fluctuating plasma medication levels.
- C. You should push the button before physical activity to allow maximum pain control.
- D. You can adjust the amount of pain medication you receive by pushing on the keypad.
Correct Answer: D
Rationale: The correct statement to include in the teaching about PCA is that the client can adjust the amount of pain medication they receive by pushing on the keypad. This empowers the client to control their pain management effectively. Choice A is incorrect because PCA systems are programmed to prevent double dosing when the button is pressed multiple times in quick succession. Choice B is incorrect as continuous PCA infusion aims to maintain a steady plasma medication level. Choice C is incorrect because it is not necessary to push the button before physical activity to ensure maximum pain control; the client should use the PCA as needed for pain relief.
A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?
- A. Teaching a new mother how to breastfeed.
- B. Assisting a client with ambulation post-surgery.
- C. Helping with medication administration.
- D. Delegating IV medication administration.
Correct Answer: B
Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.