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The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct Answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
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A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
- A. International normalized ratio (INR) of 1.0.
- B. Prothrombin time (PT) of 12 seconds.
- C. Partial thromboplastin time (PTT) of 60 seconds.
- D. International normalized ratio (INR) of 2.5.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?
- A. Apical pulse of 58 beats per minute.
- B. Serum potassium level of 3.0 mEq/L.
- C. Blood pressure of 140/90 mm Hg.
- D. Client reports seeing halos around lights.
Correct Answer: D
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.
A client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?
- A. Serum osmolality of 320 mOsm/kg.
- B. Serum glucose of 600 mg/dL.
- C. Serum potassium of 4.5 mEq/L.
- D. Serum sodium of 140 mEq/L.
Correct Answer: B
Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.
Which client has the highest risk for devel oping community-acquired pneumonia?
- A. a 40-year ol d fi rst-grade teacher w ho works w ith underprivileged children
- B. a 75-year ol d reti red secretary w ith exercise-induced w heezing
- C. a 60-year ol d homeless person who i s an alcoholic and smokes
- D. a 35-year old aerobics instructor who skips meals and eats only vegetables -
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.