Nokea
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse?
- A. Large amounts of thick white sputum.
- B. Oxygen flowmeter set on eight (8) liters.
- C. Use of accessory muscles during inspiration.
- D. Presence of a barrel chest and dyspnea.
Correct Answer: B
Rationale: High oxygen (8 LPM, B) risks CO2 retention in COPD, requiring immediate adjustment (2–4 LPM). Sputum (A), accessory muscles (C), and barrel chest (D) are expected but less urgent.
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You are providing care to a patient with COPD who is receiving medical treatment for exacerbation. The patient has a history of diabetes, hypertension, and hyperlipidemia. The patient is experiencing extreme hyperglycemia and bruising. Which medication ordered for this patient can cause hyperglycemia and bruising?
- A. Prednisone
- B. Atrovent
- C. Flagyl
- D. Levaquin
Correct Answer: A
Rationale: Prednisone , a corticosteroid, commonly causes hyperglycemia and easy bruising as side effects. Atrovent , Flagyl , and Levaquin are not typically associated with these effects.
Before recommending the use of a nonprescription decongestant to a client with a cold, which aspect of the medical history should be assessed? Select all that apply.
- A. Arthritis
- B. Asthma
- C. Hypertension
- D. Diabetes
- E. Glaucoma
- F. Arrhythmias
Correct Answer: C, E, F
Rationale: Decongestants can exacerbate hypertension, glaucoma, and arrhythmias due to their vasoconstrictive effects. Asthma is also a concern as decongestants may worsen respiratory symptoms in some cases.
The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response?
- A. Close the door and discuss the UAP's action after coming out of the room.
- B. Make the UAP come back outside the room and then reenter, closing the door.
- C. Say nothing to the UAP but report the incident to the nursing supervisor.
- D. Enter the client's room and discuss the matter with the UAP immediately.
Correct Answer: A
Rationale: Closing the door (A) maintains airborne precautions, and discussing later ensures education without disrupting care. Reentering (B) is unnecessary, reporting (C) escalates prematurely, and discussing inside (D) risks exposure.
Based on the client's clinical presentation, which drug should the nurse anticipate will be administered intravenously?
- A. Heparin
- B. Aminophylline (Truphylline)
- C. Nitroglycerin (Nitrodisc)
- D. Aspirin
Correct Answer: A
Rationale: Heparin is the standard anticoagulant used to prevent further clot formation in pulmonary embolism.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse?
- A. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup.
- B. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table.
- C. The client receiving Procrit, a biologic response modifier, has a T 99.2°F, P 68, R 24, and BP of 198/102.
- D. The client receiving prednisone, a steroid, is complaining of an upset stomach after eating breakfast.
Correct Answer: C
Rationale: Hypertension (198/102) with Procrit (C) suggests a serious side effect, requiring immediate intervention. Hemoptysis (A), tripod position (B), and stomach upset (D) are expected or less urgent.