Nokea
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
- A. Assist the client into a sitting position at 90 degrees.
- B. Administer oxygen at six (6) LPM via nasal cannula.
- C. Monitor vital signs with the client sitting upright.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sitting upright (A) improves lung expansion in COPD distress, a priority. Oxygen (B), vitals (C), and notification (D) follow to support oxygenation and communication.
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Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain?
- A. Medicate the client and have the client take deep breaths.
- B. Encourage the client to take shallow breaths to help with the pain.
- C. Explain deep breaths do not have to be taken at this time.
- D. Tell the client if he doesn't take deep breaths, he could die.
Correct Answer: A
Rationale: Pain medication followed by deep breathing (A) prevents atelectasis. Shallow breaths (B), delaying (C), and fear tactics (D) are inappropriate.
Which side effect can the nurse expect when the client receives aminophylline (Truphylline)?
- A. Bronchospasm
- B. Hypotension
- C. Drowsiness
- D. Tachycardia
Correct Answer: D
Rationale: Aminophylline, a xanthine derivative, commonly causes tachycardia as a side effect due to its stimulatory effects.
Which statement below is incorrect about a deep vein thrombosis (DVT)?
- A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral.
- B. DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too.
- C. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism.
- D. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein.
Correct Answer: C
Rationale: This option is INCORRECT. All the other statements are true about a DVT. Option C is wrong because it should say: 'A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.'
A patient is newly diagnosed with COPD due to chronic bronchitis. You're providing education to the patient about this disease process. Which statement by the patient indicates they understood your teaching about this condition?
- A. If I stop smoking, it will cure my condition.'
- B. Complications from this condition can lead to pulmonary hypertension and right-sided heart failure.'
- C. I'm at risk for low levels of red blood cells due to hypoxia and may require blood transfusions during acute illnesses.'
- D. My respiratory system is stimulated to breathe due to high carbon dioxide levels rather than low oxygen levels.'
Correct Answer: B
Rationale: Chronic bronchitis can lead to pulmonary hypertension and right-sided heart failure due to chronic hypoxemia. Smoking cessation slows progression but doesn't cure, low RBCs are not typical, and CO2 drive applies to severe cases.
A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the therapeutic INR range for this medication?
- A. 2--3
- B. 3--1
- C. 8--4
- D. 0.5-2.5
Correct Answer: A
Rationale: The therapeutic INR range is 2-3. It may be slightly higher if a patient is at a high risk for clot formation (ex: up to 4.5)