Nokea
The nurse is assessing a client with suspected pulmonary edema. Which of the following findings would support this diagnosis?
- A. Crackles in the lung bases.
- B. Bradypnea.
- C. Hypotension.
- D. Dry cough.
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in pulmonary edema.
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Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, 'Why do I have to have a blood test every week?' Which of the following responses by the nurse would be most appropriate?
- A. Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.'
- B. Weekly blood tests are done so that you can receive another week's supply of the medication.'
- C. Your physician will want to know how well you are personally progressing with the medication therapy.'
- D. Everyone who takes this drug must go through the same procedure because it is required by the drug company.'
Correct Answer: A
Rationale: Weekly blood tests monitor for agranulocytosis, a serious side effect of clozapine, ensuring safe dosing and early detection of blood abnormalities.
A client with a history of heart failure is prescribed digoxin (Lanoxin). The nurse should instruct the client to:
- A. Report signs of toxicity.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if pulse is above 100.
Correct Answer: A
Rationale: Reporting signs of digoxin toxicity (e.g., nausea, visual changes) is critical.
Which of these case management methods employs the intrinsic use of multidisciplinary plans of care that are based on the client's current condition, and reflect interventions and expected outcomes within a pre-established time line?
- A. The Case Manager Model
- B. The ProACT Model
- C. The Collaborative Practice Model
- D. The Triad Model of Case Management
Correct Answer: D
Rationale: The Triad Model of Case Management uses multidisciplinary plans of care based on the client's current condition, with interventions and expected outcomes within a pre-established timeline, involving collaboration among nursing, social work, and utilization review teams.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L per minute. The nurse assesses the client's respiratory rate at 22 breaths per minute. When the client reports an increase in the dyspnea, what should the nurse do initially?
- A. Determine the need to increase the oxygen.
- B. Call emergency services to come to the home.
- C. Reassure the client that there is no need to worry.
- D. Collect more information about the client's respiratory status.
Correct Answer: D
Rationale: Completing an assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the primary health care provider, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry.