Nokea
The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse?
- A. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24.
- B. The client's telemetry exhibits occasional premature ventricular contractions (PVCs).
- C. The client's pulse oximeter reading is 90%.
- D. The client's urinary output for the 12-hour shift is 800 mL.
Correct Answer: C
Rationale: SpO2 90% (C) indicates hypoxia in PE, requiring immediate oxygen adjustment. Normal ABGs (A), occasional PVCs (B), and urine output (D) are less urgent.
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The ABG analysis results reveal that the client's partial pressure of arterial carbon dioxide (PaCO2) is 65 mm Hg. The nurse recognizes that this is abnormal because normal PaCO2 levels fall between which values?
- A. 7.35 and 7.45
- B. 80 and 100 mm Hg
- C. 35 and 45 mm Hg
- D. 22 and 26 mm Hg
Correct Answer: C
Rationale: Normal PaCO2 levels are 35 to 45 mm Hg; a value of 65 mm Hg indicates hypercapnia, common in COPD.
Which instruction regarding the prescribed medication is most appropriate to tell this client?
- A. Do not take the drug more frequently than prescribed.
- B. Avoid taking the medication before going to sleep.
- C. Drink more fluid throughout the day.
- D. Warm the cough syrup to make it more palatable.
Correct Answer: C
Rationale: Drinking more fluids enhances the expectorant effect of guaifenesin, helping to thin and expel mucus.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates more teaching is required?
- A. It doesn't matter if I smoke now. I already have cancer.
- B. I should see the oncologist at my scheduled appointment.
- C. If I begin to run a fever, I should notify the HCP.
- D. I should plan for periods of rest throughout the day.
Correct Answer: A
Rationale: Continued smoking (A) worsens lung cancer outcomes, indicating a need for teaching. Follow-ups (B), fever reporting (C), and rest (D) are correct.
An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
- A. Keep him NPO for eight hours
- B. Prepare him to go to the operating room
- C. Explain the procedure to him
- D. Administer anticholinergic and analgesic as ordered
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures the client understands what to expect during thoracentesis.