Nokea
The client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. Which laboratory value is most concerning?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.0 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum glucose of 300 mg/dl
Correct Answer: C
Rationale: A serum bicarbonate level of 18 mEq/L is concerning in a client with COPD receiving supplemental oxygen as it indicates metabolic acidosis, which can occur due to the body compensating for chronic respiratory acidosis. This condition requires immediate intervention to restore the acid-base balance.
Choice A, serum sodium of 135 mEq/L, is within normal range (135-145 mEq/L) and not directly related to COPD or oxygen therapy. Choice B, serum potassium of 4.0 mEq/L, falls within the normal range (3.5-5.0 mEq/L) and is not typically affected by COPD or oxygen therapy. Choice D, serum glucose of 300 mg/dl, though elevated, is not directly related to COPD or oxygen therapy and would require management but is not the most concerning value in this scenario.
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The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for fever of 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct Answer: B
Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.
When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?
- A. Ask for assistance from social services to find a Korean interpreter.
- B. Establish indirect eye contact with the client.
- C. Allow several minutes for the client to respond.
- D. Repeat the question using simpler language.
Correct Answer: C
Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.
Following discharge teaching, a male client with a duodenal ulcer tells the nurse he will drink plenty of dairy products to help coat and protect his ulcer. What is the best follow-up action by the nurse?
- A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
- B. Suggest that the client also plans to eat frequent small meals to reduce discomfort.
- C. Review with the client the need to avoid foods that are rich in milk and cream.
- D. Reinforce this teaching by asking the client to list a dairy food that he might select.
Correct Answer: C
Rationale: The correct answer is C because diets rich in milk and cream stimulate gastric acid secretion, which can exacerbate a duodenal ulcer. Therefore, it is essential to avoid foods that are rich in milk and cream. Choice A is incorrect because switching to decaffeinated coffee and tea does not address the issue of avoiding milk and cream products. Choice B is incorrect because while eating frequent small meals can help with discomfort, it does not address the specific issue of avoiding milk and cream. Choice D is incorrect as it does not address the need to avoid milk and cream products.
An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
- A. Identify pills in the bag
- B. Review the client's medication schedule
- C. Assess the client's symptoms
- D. Educate the client about proper medication usage
Correct Answer: A
Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.
An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which question best assists the nurse in obtaining relevant historical data?
- A. Have you had any difficulty starting your urinary stream?
- B. Do you have a history of kidney stones?
- C. How much fluid do you drink daily?
- D. Have you had any previous urinary tract infections?
Correct Answer: A
Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.