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The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.
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During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
- A. Notify the pediatrician immediately.
- B. Teach the parents about congenital heart defects.
- C. Document the finding in the infant's record.
- D. Apply oxygen via nasal cannula at 3 L/min.
Correct Answer: C
Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.
A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I should avoid drinking alcohol to prevent irritation of my ulcer.'
- B. 'I should take my antacids regularly, even if I don't have symptoms.'
- C. 'I should avoid eating spicy foods to prevent irritation of my ulcer.'
- D. 'I should limit my caffeine intake to prevent irritation of my ulcer.'
Correct Answer: B
Rationale: The statement 'I should take my antacids regularly, even if I don't have symptoms' indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.
What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?
- A. Avoid exposure to respiratory infections.
- B. Use relaxation exercises when anxious.
- C. Continue physical therapy at home.
- D. Plan short, frequent rest periods.
Correct Answer: A
Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning to the nurse?
- A. Serum glucose of 500 mg/dL
- B. Blood pressure of 140/90 mmHg
- C. Serum osmolarity of 320 mOsm/kg
- D. Serum pH of 7.30
Correct Answer: C
Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS) as it indicates severe dehydration and hypertonicity. This high serum osmolarity level can lead to neurological complications and requires immediate intervention to prevent further deterioration. Serum glucose levels, blood pressure, and serum pH are important parameters to monitor in HHS, but a significantly elevated serum osmolarity poses a higher risk of complications and warrants urgent attention. High serum glucose levels, like 500 mg/dL, are expected in HHS but do not directly indicate the severity of dehydration. Blood pressure of 140/90 mmHg is within normal limits and may not be directly related to the acute complications of HHS. A serum pH of 7.30 suggests acidosis, which is important to address but may not be as immediately concerning as severe dehydration indicated by high serum osmolarity.
A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Instruct the client to rest until the oxygen saturation improves.
- C. Discontinue ambulation and return the client to bed.
- D. Encourage the client to breathe more deeply.
Correct Answer: C
Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.