Nokea
The nurse is applying oxygen via nasal cannula to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client complains of extreme shortness of breath. At which rate should the nurse set the flowmeter?
- A. 2 LPM.
- B. 4 LPM.
- C. 6 LPM.
- D. 10 LPM.
Correct Answer: A
Rationale: COPD clients require low-flow oxygen (2 LPM, A) to avoid CO2 retention. Higher rates (B, C, D) risk respiratory drive suppression.
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Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.
A patient is being discharged home on Doxycycline for treatment of pneumonia. Which statement by the patient indicates they understood your education material?
- A. I will wear sunscreen when outdoors.'
- B. I will avoid green leafy vegetables while taking this medication.'
- C. I will monitor my blood glucose regularly due to the side effects of hypoglycemia.'
- D. I will take this medication with a full glass of milk.'
Correct Answer: A
Rationale: Doxycycline causes photosensitivity, so wearing sunscreen is correct. Green leafy vegetables are relevant for warfarin, hypoglycemia is not a side effect, and milk can reduce doxycycline absorption.
What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.
After collecting the sputum specimen from the client, which nursing action is most appropriate?
- A. Administer oxygen
- B. Provide mouth care
- C. Offer nourishment
- D. Encourage ambulation
Correct Answer: B
Rationale: Providing mouth care after sputum collection improves client comfort and removes residual sputum from the mouth.