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A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.
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A patient with coronary artery disease (CAD) is prescribed a statin medication. What should the nurse include in the patient education?
- A. Take the medication with food.
- B. Report any muscle pain or weakness.
- C. Increase intake of grapefruit juice.
- D. Avoid foods high in potassium.
Correct Answer: B
Rationale: Step 1: Statins can cause muscle pain or weakness as a side effect.
Step 2: Prompt reporting of muscle pain or weakness is crucial to address potential myopathy or rhabdomyolysis.
Step 3: Nurse should educate patient to report any muscle symptoms promptly for timely intervention and prevention of complications.
Summary: Option B is correct as it emphasizes the importance of monitoring and reporting potential side effects of statins. Options A, C, and D are incorrect as taking with food, increasing grapefruit juice intake, and avoiding potassium-rich foods are not relevant considerations for statin therapy.
A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Notify the healthcare provider immediately. This is the priority action because the client is experiencing severe pain, swelling, warmth, and redness in the leg, which are signs of potential deep vein thrombosis (DVT) or other serious complications postoperatively. The healthcare provider needs to be informed promptly to assess and initiate appropriate treatment to prevent further complications.
A: Applying a warm compress may worsen the condition if it is DVT, as heat can promote clot formation.
B: Elevating the leg on pillows may not address the underlying cause of the symptoms and delay necessary intervention.
C: Measuring the circumference of the leg may provide some information, but it is not as urgent as notifying the healthcare provider for immediate assessment and intervention.
The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
What is the most appropriate nursing intervention to help alleviate severe abdominal pain in a patient with acute pancreatitis?
- A. Encourage oral intake of clear fluids.
- B. Place the patient in a supine position.
- C. Administer prescribed opioid analgesics.
- D. Apply a heating pad to the abdomen.
Correct Answer: C
Rationale: The correct answer is C, administering prescribed opioid analgesics. This intervention is appropriate for severe abdominal pain in acute pancreatitis as opioids are effective in managing pain. Encouraging oral intake (A) can worsen symptoms, a supine position (B) can exacerbate pain, and a heating pad (D) can aggravate inflammation. Administering opioid analgesics provides direct pain relief and is the most effective intervention for alleviating severe abdominal pain in acute pancreatitis.
During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?
- A. Right upper quadrant pain
- B. Left lower quadrant pain
- C. Generalized abdominal pain
- D. Epigastric pain
Correct Answer: A
Rationale: The correct answer is A: Right upper quadrant pain. Cholecystitis is inflammation of the gallbladder, typically caused by gallstones. The gallbladder is located in the right upper quadrant of the abdomen, so pain in this area is a common symptom. The pain may also radiate to the back or right shoulder. Choices B, C, and D are incorrect because they do not typically align with the specific location of the gallbladder or the characteristic pain associated with cholecystitis.