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The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.
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The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially?
- A. Stop the infusion immediately.
- B. Apply a sterile, occlusive dressing.
- C. Ensure all IV tubing connections are tight.
- D. Gather the supplies needed to insert a new IV.
Correct Answer: C
Rationale: To determine subsequent nursing interventions, the nurse checks all connections to ensure tight seals while the IV infuses to help locate the source of the leak. If the leak is at the insertion site, the nurse stops the infusion, removes the IV, and inserts a new IV catheter. The nurse applies a new sterile occlusive dressing after resolving the source of the leak.
The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation should provide which information? Select all that apply.
- A. Eat bland foods.
- B. Avoid alcohol ingestion.
- C. Avoid cigarette smoking.
- D. Avoid caffeinated beverages.
- E. Eat small meals and snacks high in calories.
- F. Eat high-fat, low-protein, high-carbohydrate meals.
Correct Answer: A,B,C,D,E
Rationale: Chronic pancreatitis is a progressive, destructive disease of the pancreas, characterized by remissions and exacerbations (recurrence). Measures to prevent an exacerbation include eating bland, low-fat, high-protein, moderate-carbohydrate meals; avoiding alcohol ingestion, nicotine, and caffeinated beverages; eating small meals and snacks high in calories; and avoiding gastric stimulants such as spices.
A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation should the nurse monitor the client for? Select all that apply.
- A. Pallor
- B. Dizziness
- C. Diaphoresis
- D. Bradycardia
- E. Constipation
- F. Extreme thirst
Correct Answer: A,B,C
Rationale: Dumping syndrome is the rapid emptying of the gastric contents into the small intestine that occurs after gastric resection. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Manifestations also include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
- A. Assist the client to develop a daily bowel routine to prevent constipation.
- B. Teach the client to manage emotional stressors by using mental imaging.
- C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
- D. Administer dexamethasone orally per the primary health care provider's prescription.
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.