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A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?
- A. Encourage the client to take deep breaths.
- B. Administer oxygen as needed.
- C. Teach the client pursed-lip breathing.
- D. Limit the client's fluid intake.
Correct Answer: C
Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.
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A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
- A. Avoid eating small, frequent meals.
- B. Sleep with the head of your bed elevated.
- C. Lie down after eating.
- D. Avoid drinking fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.
How should fluid overload in a patient with heart failure be managed?
- A. Administer diuretics
- B. Increase fluid intake
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
A healthcare professional is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?
- A. Postprandial blood glucose
- B. Glycosylated hemoglobin (HbA1c)
- C. Glucose tolerance test
- D. Fasting blood glucose
Correct Answer: B
Rationale: Glycosylated hemoglobin (HbA1c) is the most accurate test for long-term management of blood glucose levels in individuals with diabetes mellitus. HbA1c reflects average blood glucose levels over the past 2-3 months, providing valuable information on the effectiveness of treatment and disease control. Postprandial blood glucose, glucose tolerance test, and fasting blood glucose are essential for monitoring blood glucose levels at specific times but do not offer the same insight into long-term disease management as HbA1c.
A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypoglycemia
- C. Diaphoresis
- D. Tachycardia
Correct Answer: A
Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.