Nokea
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
- A. Monitor dryness of mucous membranes
- B. Check for changes in mentation
- C. Observe color of skin and nailbeds
- D. Note appearance of jugular veins
Correct Answer: B
Rationale: Changes in mentation, skin color, and breathing patterns are key indicators of hypoxia in clients with lung disease.
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A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until color returns to normal
Correct Answer: D
Rationale: Monitoring is appropriate as the symptoms are consistent with Raynaud's phenomenon and should resolve with warming.
Severe pulmonary valve stenosis is defined as a peak gradient of
- A. >40 mm Hg
- B. >45 mm Hg
- C. >50 mm Hg
- D. >55 mm Hg
Correct Answer: C
Rationale: Severe pulmonary valve stenosis is generally defined as a peak gradient >50 mm Hg.
While looking through the chart of an infant with a congenital heart defect (CHD) of decreased pulmonary blood flow, the nurse would expect which laboratory finding?
- A. Decreased platelet count
- B. Decreased ferritin level
- C. Respiratory alkalosis
- D. Polycythemia
Correct Answer: D
Rationale: Polycythemia is often seen in infants with congenital heart defects that cause decreased pulmonary blood flow, as the body produces more red blood cells to compensate for low oxygen levels.
Nystagmus can be a presenting sign in:
- A. Partial albinism
- B. Retinopathy of prematurity
- C. Acute vestibulitis
- D. Medulloblastoma
Correct Answer: D
Rationale: Medulloblastoma, a type of brain tumor, can present with nystagmus due to its impact on the cerebellum and brainstem.