Nokea
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 94%
- C. Carbon dioxide level of 45 mmHg
- D. Respiratory rate of 20 breaths per minute
Correct Answer: C
Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.
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Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?
- A. Distal pulse intensity
- B. Skin integrity
- C. Pain levels
- D. Range of motion
Correct Answer: A
Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.
A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?
- A. Confusion and altered mental status
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Peripheral edema
Correct Answer: A
Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.
In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
- A. Note the appearance and patency of the client's peripheral IV site.
- B. Palpate the volume of the client's right radial pulse.
- C. Auscultate the client's breath sounds bilaterally.
- D. Observe the amount and dose of morphine in the PCA pump syringe.
Correct Answer: D
Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
- A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
- B. Validate the nurse is implementing the OR policy for surgical hand scrub
- C. Inform the nurse that hand scrubs should be 3 minutes between cases.
- D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
Correct Answer: D
Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.
A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?
- A. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam.
- B. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces of coffee.
- C. Banana pancake with maple syrup, sausage links, half grapefruit, and low-fat milk.
- D. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.
Correct Answer: B
Rationale: The correct answer is B. Oatmeal with butter, artificial sweetener, and strawberries is a suitable choice for a client with type 2 diabetes mellitus and chronic kidney disease as it provides a balanced meal that helps manage blood sugar levels and kidney function. Choice A contains high saturated fats and added sugars from bacon, butter, and jam, which are not ideal for this client. Choice C includes high sugar content from maple syrup and pancake, which can negatively impact blood sugar levels. Choice D contains high sugar content from orange juice and cold cereal, which can lead to blood sugar spikes, not suitable for a client with diabetes and CKD.