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A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
- A. Increase the oxygen flow to 3 L/min.
- B. Assess the client's respiratory status.
- C. Call emergency services for the client.
- D. Have the client cough and expectorate secretions.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. This is the priority because the client is experiencing difficulty breathing, which could indicate a worsening of their condition. By assessing the respiratory status, the nurse can gather vital information to determine the appropriate next steps, such as adjusting the oxygen flow rate, providing respiratory treatments, or seeking further medical intervention. Increasing the oxygen flow without assessing the client's condition could potentially exacerbate the issue. Calling emergency services (choice C) may be necessary based on the assessment findings but should not be the immediate priority. Having the client cough and expectorate secretions (choice D) is important for airway clearance but is not the priority when the client is in distress.
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A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?
- A. Bradycardia
- B. Bradypnea
- C. Lethargy
- D. Intercostal retractions
Correct Answer: D
Rationale: The correct answer is D: Intercostal retractions. In postoperative atelectasis, there is a collapse of lung tissue leading to decreased oxygen exchange and hypoxia. Intercostal retractions indicate increased work of breathing as the body tries to compensate for the decreased lung function. Bradycardia and bradypnea are not typically associated with hypoxia but rather with decreased oxygen delivery to tissues. Lethargy is a nonspecific symptom and may not directly correlate with hypoxia in this scenario.
14. A patient newly diagnosed with type 2 diabetes has been given a prescription to start on an oral hypoglycemic. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take?
- A. Advise the patient to discuss using herbal therapy with her physician.
- B. Advise the patient that herbal therapy is not safe and should not be used.
- C. Advise the patient to give the prescriptive medication time to work before using herbal therapy.
- D. Advise the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.
Correct Answer: A
Rationale: Referring the patient to her physician (option A) ensures that any decision regarding herbal therapy is made collaboratively and safely.
A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?
- A. Provide the client with supplemental oxygen at 5 L/min via facemask.
- B. Place the client in high-Fowler's position with their legs in a dependent position
- C. Give the client sublingual nitroglycerin
- D. Administer morphine sulfate IV
Correct Answer: A
Rationale: The correct answer is A: Provide the client with supplemental oxygen at 5 L/min via facemask. In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress, reducing the workload on the heart. This intervention addresses the client's dyspnea and anxiousness by improving oxygen delivery.
Choice B is incorrect as placing the client in high-Fowler's position with legs in a dependent position can help with breathing but does not address the immediate need for oxygenation.
Choice C is incorrect as sublingual nitroglycerin is typically used for angina and not the priority intervention for cardiogenic pulmonary edema.
Choice D is incorrect as morphine sulfate IV may be indicated for pain relief and anxiety, but it is not the priority intervention to address the client's oxygenation needs in cardiogenic pulmonary edema.
An 88-year-old woman is brought to the health clinic for the first time by her 64-year-old daughter. During the initial comprehensive nursing assessment of the patient, what should the nurse do?
- A. Ask the daughter whether the patient has any urgent needs or problems.
- B. Interview the patient and daughter together so that pertinent information can be confirmed.
- C. Obtain a health history using a functional health pattern and assess activities of daily living (ADLs) and mental status.
- D. Refer the patient for an interdisciplinary comprehensive geriatric assessment because at her age she will have multiple needs.
Correct Answer: C
Rationale: Assessing ADLs, mental status, and obtaining a thorough health history ensures comprehensive understanding of the patient's needs.
A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?
- A. Severe dyspnea
- B. Nausea
- C. Decreased level of consciousness
- D. Headache
Correct Answer: B
Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.