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A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of an exacerbation?
- A. Increased sputum production.
- B. Decreased respiratory rate.
- C. Low blood pressure.
- D. High fever.
Correct Answer: A
Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production.
2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort.
3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications.
4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.
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A nurse is assessing a patient's hydration status. Which of the following findings would suggest dehydration?
- A. Increased urine output
- B. Decreased heart rate
- C. Dry mucous membranes
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Dry mucous membranes. Dry mucous membranes are a common sign of dehydration as the body lacks adequate fluid. When a person is dehydrated, there is a decrease in saliva production, leading to dryness in the mouth and throat. This can be easily observed during a physical examination by looking at the patient's lips, tongue, and inside of the mouth. On the other hand, increased urine output (choice A) is a sign of adequate hydration, decreased heart rate (choice B) can be a normal response to dehydration but is not a consistent indicator, and increased blood pressure (choice D) is not typically associated with dehydration. Therefore, dry mucous membranes are the most reliable finding to suggest dehydration in a patient.
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions to prevent complications?
- A. Administering pain medication as needed.
- B. Encouraging early ambulation and use of compression stockings.
- C. Providing nutritional support and supplements.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation and use of compression stockings. This intervention is crucial post-hip replacement to prevent complications such as blood clots and muscle weakness. Early ambulation helps prevent blood clots by promoting circulation, and compression stockings further aid in preventing deep vein thrombosis. Pain medication (A) is important but not the priority in preventing complications. Providing nutritional support (C) is also important but does not directly prevent post-operative complications. Monitoring for signs of infection (D) is essential but not as immediate as promoting early ambulation to prevent complications.
A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
- A. Could not give four unrelated words within 5 minutes.
- B. Could not give four unrelated words within 30 seconds.
- C. Could not recall four unrelated words after a 30-minute delay.
- D. Could not recall four unrelated words after a 60-minute delay.
Correct Answer: C
Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
A nurse is teaching a patient about managing asthma. Which of the following statements by the patient indicates a need for further education?
- A. I will take my rescue inhaler only during an asthma attack.
- B. I should avoid exposure to allergens that trigger my symptoms.
- C. I will use my inhaler before exercise to prevent symptoms.
- D. I should always carry my inhaler with me.
Correct Answer: A
Rationale: The correct answer is A: I will take my rescue inhaler only during an asthma attack. This statement indicates a need for further education because using a rescue inhaler only during an asthma attack is not the correct way to manage asthma. The purpose of a rescue inhaler is to provide quick relief during an asthma attack, but it should also be used as a preventive measure before exposure to known triggers or before exercise to prevent symptoms. Options B, C, and D all demonstrate good understanding of asthma management by indicating the importance of avoiding triggers, using the inhaler preventively, and carrying the inhaler at all times for emergency situations.
A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administering pain medication.
- B. Monitoring vital signs and oxygen saturation.
- C. Encouraging deep breathing exercises.
- D. Providing nutritional education.
Correct Answer: B
Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.