Nokea
The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate to include in the care plan?
- A. Instruct the client to use pursed-lip breathing
- B. Recommend a high-fat, low-carbohydrate diet
- C. Limit physical activity to prevent shortness of breath
- D. Encourage the client to drink large amounts of fluids
Correct Answer: A
Rationale: The correct answer is A: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and reduce shortness of breath in COPD clients. This technique involves inhaling slowly through the nose and exhaling through pursed lips. Choice B is incorrect because a high-fat, low-carbohydrate diet is not recommended for individuals with COPD as it can lead to weight gain and worsen respiratory function. Choice C is incorrect as limiting physical activity can lead to deconditioning and worsen COPD symptoms. Regular, moderate exercise is beneficial for individuals with COPD. Choice D is incorrect as excessive fluid intake can strain the heart in COPD clients. It is important to maintain adequate but not excessive fluid intake to prevent dehydration and maintain optimal lung function.
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When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?
- A. To reduce abdominal pressure on the diaphragm
- B. To promote retraction of the intercostal accessory muscles of respiration
- C. To promote bronchodilation and effective airway clearance
- D. To decrease pressure on the medullary center which stimulates breathing
Correct Answer: A
Rationale: Elevating the head of the bed to 30 degrees is done to reduce abdominal pressure on the diaphragm, aiding in lung expansion and oxygenation. This position helps improve respiratory mechanics by allowing the diaphragm to move more effectively. Choice B is incorrect as elevating the head of the bed does not directly promote retraction of the intercostal accessory muscles of respiration. Choice C is incorrect because although elevating the head of the bed can assist with airway clearance, its primary purpose in ARDS is to decrease pressure on the diaphragm. Choice D is incorrect because reducing pressure on the medullary center is not the main goal of elevating the head of the bed; the focus is on enhancing lung function and oxygen exchange.
An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
- A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
- B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
- C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
- D. Encourage the client to avoid becoming involved in the neighbor's problems for one's protection.
Correct Answer: C
Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor's safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.
After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
- A. Perform a finger stick glucose test
- B. Increase the IV fluid flow rate
- C. Review 24-hour intake and output
- D. Obtain arterial blood gases
Correct Answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
- A. Verbalizes a fear of being in a confined space.
- B. Drank a glass of water in the past 2 hours.
- C. Reports left chest wall pain prior to admission.
- D. Experiences facial swelling after eating crab
Correct Answer: C
Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.
A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
- A. Wear a dosimeter film badge when in the client's room
- B. Spend 30 minutes at the bedside when providing direct care
- C. Change the linens every day after assisting with a bed bath
- D. Use gloves to remove the applicator if it is dislodged in the bed
Correct Answer: A
Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client's room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.