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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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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.
A 24-year-old female client who has a history of rheumatoid arthritis (RA) is taking ibuprofen (Motrin) for pain relief. Which information should the nurse provide the client about taking this medication?
- A. Take the medication with meals
- B. Take the medication with an antacid
- C. Report any changes in stool color to your healthcare provider
- D. Avoid taking aspirin while using this medication
Correct Answer: C
Rationale: The correct answer is to instruct the client to report any changes in stool color to the healthcare provider. This is important because changes in stool color can indicate gastrointestinal bleeding, a serious side effect of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Choice A is incorrect because while taking ibuprofen with meals can help reduce stomach upset, it is not the most crucial information to provide. Choice B is incorrect as taking ibuprofen with an antacid is not a standard recommendation. Choice D is also incorrect because while ibuprofen and aspirin are both NSAIDs, they can be taken together under certain circumstances, but it's important to be cautious and follow healthcare provider recommendations.
A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?
- A. Remind the client that it is also important to schedule an annual mammogram
- B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
- C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
- D. Instruct the client to continue with her regular monthly exams as she is doing
Correct Answer: C
Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.
The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?
- A. Reposition the client every 2 hours
- B. Cleanse the ulcer with normal saline
- C. Apply a moisture-retentive dressing
- D. Measure the ulcer's depth and diameter
Correct Answer: D
Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.
In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?
- A. Pink lips and tongue with cyanotic hands and feet
- B. Respiration rate of 40 and heart rate of 144
- C. Centralized cyanosis and tachycardia when crying
- D. Desquamation from areas of cracked, parchment-like skin
Correct Answer: C
Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.