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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Blood pressure of 110/70 mmHg
Correct Answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.
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A client is admitted with a diagnosis of septic shock. Which clinical finding requires immediate intervention?
- A. Blood pressure of 90/60 mmHg
- B. Temperature of 100.4°F
- C. Heart rate of 120 beats per minute
- D. Urine output of 30 ml/hour
Correct Answer: C
Rationale: In a client with septic shock, a heart rate of 120 beats per minute is a critical clinical finding that requires immediate intervention. A rapid heart rate can indicate worsening sepsis and inadequate tissue perfusion. Correcting the underlying cause of the tachycardia and stabilizing the heart rate is crucial in managing septic shock. The other options, while important, do not represent an immediate threat to the patient's condition. A blood pressure of 90/60 mmHg may be expected in septic shock, a temperature of 100.4°F is mildly elevated, and a urine output of 30 ml/hour, though decreased, may not be an immediate concern in the context of septic shock.
A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?
- A. Serum potassium of 3.0 mEq/L
- B. Serum sodium of 135 mEq/L
- C. Serum creatinine of 1.5 mg/dl
- D. Blood glucose of 200 mg/dl
Correct Answer: A
Rationale: A serum potassium level of 3.0 mEq/L requires immediate intervention in a client receiving furosemide. Furosemide can cause potassium loss, leading to hypokalemia, which can be dangerous, especially in patients with heart failure. Hypokalemia can predispose the client to cardiac dysrhythmias, weakness, and other complications. Therefore, prompt intervention is necessary to prevent these adverse effects.
Choice B (Serum sodium of 135 mEq/L) is within the normal range and does not require immediate intervention. Choice C (Serum creatinine of 1.5 mg/dl) may indicate kidney dysfunction but does not pose an immediate threat to the client's safety. Choice D (Blood glucose of 200 mg/dl) may suggest hyperglycemia, which is important but not as urgent as addressing hypokalemia in a client with heart failure receiving furosemide.
The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Elevated liver enzymes
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.
A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?
- A. Sitting up and leaning forward
- B. Lying flat with legs elevated
- C. Lying on the side with the head slightly raised
- D. Sitting up and tilting the head back
Correct Answer: A
Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.
Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?
- A. I am having pain in my lower back when I move my legs
- B. My throat hurts when I swallow
- C. I feel sick to my stomach and am going to throw up
- D. I have a headache that gets worse when I sit up
Correct Answer: D
Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.