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The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.
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Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
- A. The client requests a consultation by the speech therapist.
- B. The client has a towel placed over the mirror.
- C. The client is attempting to shave himself.
- D. The client practices neck and shoulder exercises.
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.
The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion?
- A. The client's arterial blood gases are within normal limits.
- B. The client appears anxious, has dyspnea, and is tachypneic.
- C. The client has intercostal retractions and is using accessory muscles.
- D. The client has bilateral lung sounds with crackles and rhonchi.
Correct Answer: C
Rationale: Intercostal retractions and accessory muscle use (C) indicate severe respiratory distress, consistent with ARDS due to increased work of breathing from reduced lung compliance. Normal ABGs (A) contradict ARDS, which involves hypoxia. Anxiety, dyspnea, and tachypnea (B) are non-specific. Crackles and rhonchi (D) may occur but are less specific than physical signs of distress.
The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include?
- A. Refer the client to the American Lung Association.
- B. Notify the physical therapy department to arrange for activity training.
- C. Arrange for oxygen therapy to be used at home.
- D. Discuss advance directives with the client.
Correct Answer: C
Rationale: Bronchiolitis obliterans causes irreversible airway obstruction, often requiring home oxygen therapy (C) to manage hypoxemia, a priority for discharge planning. Referrals (A), physical therapy (B), and advance directives (D) are important but secondary to ensuring oxygenation.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.