Nokea
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
- A. Temperature 100°F
- B. Oxygen saturation 88%
- C. Blood pressure 130/80 mmHg
- D. Heart rate 98 beats/min
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system. Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up. Choices E, F, and G are not relevant findings in this scenario.
You may also like to solve these questions
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
- A. I can place an extension cord across my living room to plug in my television.
- B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- C. I will place my alarm clock on my bedroom dresser across the room.
- D. I will replace the old throw rug in my kitchen with a new one.
Correct Answer: B
Rationale: Correct Answer: B - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
Rationale: This statement demonstrates understanding as it shows awareness of potential hazards (low-hanging tree) that could obstruct safe walker use. By hiring someone to trim the tree, the client is proactively ensuring a safe environment for mobility with the walker.
Summary of Incorrect Choices:
A: Placing an extension cord across the living room poses a tripping hazard, which is unsafe for walker use.
C: Placing the alarm clock on the bedroom dresser is unrelated to walker safety.
D: Replacing the throw rug in the kitchen is beneficial but not directly related to walker safety.
A nurse is caring for a client who has a terminal illness, and the client's partner indicates effective coping. The nurse should recognize that which of the following statements is an indication of effective coping?
- A. I am not worried because I will have hope that he will be okay.
- B. I am relying on support from our family during this time.
- C. We can plan our family reunion once he recovers and comes home.
- D. We don't see any reason to start discussing funeral arrangements right now.
Correct Answer: B
Rationale: The correct answer is B: "I am relying on support from our family during this time." This statement indicates effective coping because it acknowledges the importance of seeking and utilizing support from family members, which can help reduce feelings of isolation and provide emotional strength. By relying on family support, the client's partner is demonstrating a healthy coping mechanism that promotes resilience and emotional well-being during a challenging situation.
Choice A is incorrect because relying solely on hope without acknowledging the need for support may not address the partner's emotional needs effectively. Choice C is incorrect as it demonstrates denial of the terminal illness and avoidance of the current reality. Choice D is incorrect as it suggests avoidance of discussing important end-of-life decisions, which can hinder effective coping and planning.