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A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person, place, and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic, cough is productive, and mucous is yellow in color.
- E. Wheezes and crackles heard upon auscultation.
Correct Answer: D
Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status. Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.
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A nurse is caring for a client who has heart failure. Drag words from the choices below to fill
in each blank in the following sentence. The client is at risk for developing _________ and_________
Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin.The client has prescriptions for regular and NPH insulins. Which
of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A: I will draw up the regular insulin into the syringe first.
Rationale: Drawing up regular insulin first is crucial for preventing contamination between the two insulins. Regular insulin is a clear solution and should be drawn up first to prevent any cloudiness or contamination from the NPH insulin, which is a cloudy suspension. Drawing up regular insulin first ensures accuracy in dosing and prevents mixing of the two insulins.
Incorrect Choices:
B: Shaking the NPH vial vigorously before drawing up the insulin is incorrect as it can cause bubbles and affect the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle pointed downward is incorrect as it can lead to leakage or contamination.
D: Inserting the needle at a 15-degree angle is incorrect as insulin injections should be administered at a 90-degree angle for proper absorption.
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through airborne transmission, so implementing airborne precautions is essential to prevent the spread of the disease. This includes wearing an N95 mask, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (choice A) are used for all clients, not specifically for tuberculosis. Contact precautions (choice C) are used for diseases spread by direct contact, while droplet precautions (choice D) are used for diseases spread through respiratory droplets, not airborne transmission like tuberculosis.
A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome?
- A. Thyroidectomy
- B. Repair of a torn rotator cuff
- C. Internal fixation of a fractured hip
- D. Tympanoplasty
Correct Answer: C
Rationale: The correct answer is C: Internal fixation of a fractured hip. Fat embolism syndrome (FES) typically occurs in long bone fractures or orthopedic surgeries like hip fixation due to fat droplets entering the bloodstream. These fat droplets can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rash. In contrast, choices A, B, and D are not associated with a high risk of FES. Thyroidectomy involves removal of the thyroid gland, repair of torn rotator cuff involves shoulder surgery, and tympanoplasty involves repairing the eardrum, none of which typically lead to fat embolism.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.