Nokea
The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?
- A. Nasal congestion
- B. Cough
- C. Sore throat
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.
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A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice, and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.
The nurse is preparing to administer insulin to a client with type 1 diabetes. Which assessment finding would require the nurse to hold the insulin and contact the healthcare provider?
- A. Blood glucose of 100 mg/dL
- B. Client reports feeling shaky
- C. Client ate only half of breakfast
- D. Client is sweating
Correct Answer: A
Rationale: A blood glucose of 100 mg/dL is relatively low for administering insulin, especially if the client has not eaten adequately; further assessment and contacting the provider are necessary. Hypoglycemia can be a serious concern when administering insulin, and a blood glucose level of 100 mg/dL indicates a risk of hypoglycemia. Holding the insulin and contacting the healthcare provider is crucial to prevent hypoglycemia-related complications. Choices B, C, and D are not immediate concerns for holding insulin as they do not directly indicate a risk of hypoglycemic events.
The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?
- A. Offer small sips of water through a straw
- B. Place tongue blade on back half of tongue
- C. Use a penlight to observe back of the oral cavity
- D. Auscultate breath sounds after the client swallows
Correct Answer: B
Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.
When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct Answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?
- A. Assess the client's respiratory rate and effort.
- B. Measure the client's oxygen saturation level.
- C. Monitor the client's arterial blood gas levels.
- D. Check the client's blood pressure.
Correct Answer: B
Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.