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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?
- A. Administer a bronchodilator
- B. Encourage deep breathing and coughing
- C. Assess the client's oxygen saturation level
- D. Obtain an arterial blood gas
Correct Answer: C
Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.
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Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?
- A. Dorsiflexes the right foot and left on command
- B. A 3 by 5 cm ecchymosis area covering the right calf
- C. Right calf is 3 cm larger in circumference than the left
- D. Bilateral lower extremity has 3+ pitting edema
Correct Answer: C
Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.
The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?
- A. Assess the client's oxygen saturation level
- B. Teach the client pursed-lip breathing techniques
- C. Determine the client's history of lung disease
- D. Obtain an arterial blood gas sample
Correct Answer: A
Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.
When obtaining an admission history for a client who is at 9 weeks gestation, the client states, 'I had a miscarriage 2 years ago.' Which information is most important for the nurse to obtain?
- A. How long was your previous pregnancy?
- B. How long did it take for you to become pregnant after your miscarriage?
- C. Was your miscarriage during the first trimester?
- D. Do you have any children now?
Correct Answer: A
Rationale: The correct answer is A. Understanding the duration of the previous pregnancy helps assess the client's obstetric history. Choice B focuses on the time it took to conceive after the miscarriage, which is less relevant at this point. Choice C asks about the timing of the miscarriage rather than the duration of the previous pregnancy. Choice D inquires about the current status of having children, which is not directly related to the client's obstetric history.
A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?
- A. It helps my body make red blood cells
- B. It helps prevent infections
- C. It helps my kidneys excrete excess fluid
- D. It helps me breathe easier
Correct Answer: A
Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.
A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct Answer: A
Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.