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A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- A. Increased oxygen saturation with exercise.
- B. Pursed-lip breathing with exertion.
- C. Productive cough with clear sputum.
- D. Clubbing of the fingers.
Correct Answer: C
Rationale: The correct answer is C: 'Productive cough with clear sputum.' Clients with COPD often have a chronic productive cough with thick, often purulent sputum. This sputum can be white, yellow, green, or clear. Choices A, B, and D are incorrect. Oxygen saturation may decrease with exertion in COPD due to impaired gas exchange. Pursed-lip breathing is used to control dyspnea, not directly related to increased saturation with exercise. Clubbing of the fingers is typically seen in conditions such as cyanotic heart disease or lung cancer.
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A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who was just given a glass of orange juice for a low blood glucose level.
- B. A client who is scheduled for a procedure in 1 hr.
- C. A client who has 100 mL of fluid remaining in his IV bag.
- D. A client who received a pain medication 30 min ago for postoperative pain.
Correct Answer: A
Rationale: A client with low blood glucose levels needs immediate assessment to ensure stabilization. Hypoglycemia can lead to serious complications if not addressed promptly. The other options do not present immediate life-threatening situations that require urgent assessment. Option B can be attended to after addressing the client with low blood glucose levels. Option C can be managed based on the infusion rate and the client's condition. Option D, although important, can be assessed after ensuring the client with low blood glucose levels is stable.
A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication using a tuberculin syringe
- B. Administer the medication at a 45-degree angle
- C. Use the dorsogluteal muscle for injection
- D. Aspirate for blood return before injecting the medication
Correct Answer: D
Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.
A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with milk.
- B. I should expect my stools to turn black.
- C. I should avoid eating oranges while taking this medication.
- D. I will take this medication on an empty stomach.
Correct Answer: B
Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.