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The nurse is planning care for a client with a long history of smoking and newly diagnosed chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include in the client's teaching plan?
- A. Explain the need to avoid large crowds during the winter months.
- B. Instruct the client to install air conditioning in the home.
- C. Teach the client to breathe in through the nose and out through the mouth.
- D. Encourage the client to consume three large meals daily.
Correct Answer: A
Rationale: Clients with COPD are at high risk for respiratory infections, which can exacerbate symptoms. Avoiding large crowds during winter reduces exposure to viruses. Options B, C, and D are less relevant: air conditioning is not essential, nasal breathing is not specific, and large meals can cause dyspnea due to gastric pressure.
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The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-gastrectomy complication. Options A, C, and D are normal.
A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
- A. Say to him, 'There is no one there. Keep your voice down.'
- B. Escort the client to his room
- C. Restrain the client
- D. Offer PRN haloperidol (Haldol) as ordered
Correct Answer: B
Rationale: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.