Nokea
The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement?
- A. Praise the UAP because this prevents the client from tripping on the oxygen tubing.
- B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
- C. Explain to the UAP in front of the client oxygen must be left in place at all times.
- D. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Correct Answer: B
Rationale: COPD clients need continuous oxygen; replacing it (B) corrects the error safely. Praising (A) is incorrect, explaining in front of client (C) is unprofessional, and escalating (D) is premature.
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The term 'blue bloaters' is used to describe patients with?
- A. Pulmonary hypertension
- B. Left-sided heart failure
- C. Chronic Bronchitis
- D. Emphysema
Correct Answer: C
Rationale: Blue bloaters' describes chronic bronchitis patients, who present with cyanosis ('blue') and edema ('bloating') due to hypoxemia and right heart failure. Emphysema patients are often called 'pink puffers.'
The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription?
- A. These pills will make me feel better fast and I can return to work.
- B. The antibiotics will help prevent me from developing a bacterial pneumonia.
- C. If I had gotten this prescription sooner, I could have prevented this illness.
- D. I need to take these pills until I feel better; then I can stop taking the rest.
Correct Answer: B
Rationale: Antibiotics for influenza (B) prevent secondary bacterial pneumonia, not treat the virus. Quick recovery (A), prevention (C), and stopping early (D) are incorrect.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
- A. Assess the client for abnormal bleeding.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Administer the medication as ordered.
- D. Notify the HCP to obtain an order to increase the dose.
Correct Answer: C
Rationale: INR 2.8 (C) is therapeutic for PE (2–3), so administer warfarin. Bleeding assessment (A) is routine, vitamin K (B) reverses overdose, and increasing dose (D) is unnecessary.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.
A patient's D-dimer result is <500 ng/mL (FEU). The nurse knows that the D-dimer assesses and this result means?
- A. fibrin degradation fragment; positive for a blood clot
- B. platelet degradation protein; negative for a blood clot
- C. clotting factors; positive for a blood clot
- D. fibrin degradation fragment; negative for a blood clot
Correct Answer: D
Rationale: A d-dimer test assess fibrin degradation fragment. This test doesn't tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn't necessarily mean the patient has a clot because some disease processes can cause a false positive. Also, a normal d-dimer is <500 ng/mL (FEU). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Some labs have a cutoff <250 ng/mL (D-DU). However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU).