Nokea
An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client “looks like he is having difficulty getting air.” What should the nurse’s initial action be?
- A. Thank the client’s sister and continue to observe the client
- B. Immediately decrease the oxygen
- C. Notify the physician
- D. elevate client’s head and take her vital signs
Correct Answer: C
Rationale: The correct initial action for the nurse is to choose option C: Notify the physician. Increasing oxygen without a healthcare provider's order can be harmful, especially in COPD patients prone to retaining carbon dioxide. The nurse should communicate the situation to the physician to assess the client's condition and adjust the oxygen therapy appropriately. Option A is incorrect as it neglects the potential risks of high oxygen levels. Option B is incorrect as immediate decrease without proper assessment can be dangerous. Option D is not the priority when the client's oxygen therapy needs evaluation.
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A 68-year old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
- A. Diabetes mellitus
- B. Hypoparathyroidism
- C. Diabetes insipidus
- D. Hyperparathyroidism
Correct Answer: D
Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.
The first thing to do for a nurse when an accident occurs is to find out if patient is conscious so that she could:
- A. Reassure the patient
- B. Call relatives
- C. Bring patient immediately to the hospital
- D. Call a doctor
Correct Answer: A
Rationale: The correct answer is A: Reassure the patient. The first priority in any accident scenario is to ensure the patient's safety and well-being. By checking if the patient is conscious, the nurse can assess their immediate condition and provide reassurance to alleviate any distress or anxiety. This step establishes communication and trust, allowing for further assessment and appropriate actions to be taken. Calling relatives (B) may be important but not the immediate first step. Bringing the patient immediately to the hospital (C) is premature without assessing the patient first. Calling a doctor (D) can be done after assessing the patient's condition.
A client agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
- A. Blood relationship
- B. Compatible blood and tissue types
- C. Sex and size
- D. Need
Correct Answer: B
Rationale: The correct answer is B: Compatible blood and tissue types. This is crucial to minimize the risk of rejection and ensure a successful transplant. Matching blood and tissue types help prevent the recipient's immune system from attacking the new organ. Blood relationship (A) is not as important as compatibility. Sex and size (C) are important considerations for certain transplants but not the most crucial factor. Need (D) is relevant but does not outweigh the importance of compatibility to ensure a successful transplant.
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: A
Rationale: The correct answer is A: Bladder control. This is the major early problem for Mr. Gabatan because urinary retention is a common complication post-surgery, especially for older males like him. Bladder control is essential for preventing urinary tract infections and maintaining overall health. Quadriceps setting (B) and client education (C) are important but not as critical early on. Use of aids for ambulation (D) is important but not the major early problem compared to bladder control in this case.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Keep extremities at neutral position. This intervention promotes proper blood flow and reduces the risk of thrombophlebitis by preventing compression or restriction of blood vessels. Removing and reapplying elastic stockings (choice A) can disrupt circulation and increase the risk of thrombophlebitis. Changing the client's position (choice C) may not directly address hemostasis or thrombophlebitis. Using a flotation mattress (choice D) is not specifically focused on maintaining proper positioning of the extremities to promote circulation.