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The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
- A. Administer albuterol nebulizer
- B. Assist the client in identifying the trigger and ways to avoid it
- C. Coach the client through controlled breathing exercises
- D. Continue to monitor oxygen saturation
Correct Answer: C
Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.
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The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
- A. Apply the patch when the ship starts moving and not before.'
- B. Dispose of the patch out of reach of children and pets.'
- C. Ensure that the old patch is removed before applying a new one.'
- D. Place the patch on a hairless, clean, dry area behind the ear.'
- E. Wash your hands with soap and water after handling the patch.'
Correct Answer: B,C,D,E
Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway
- B. Call for help
- C. Establish that the client is unresponsive
- D. See if anyone saw the client fall
Correct Answer: C
Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.
The nurse in a clinic is caring for an 8-month-old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent?
- A. Administration of a cough suppressant and an antihistamine
- B. Prophylactic treatment of family members
- C. Temporary cessation of breastfeeding
- D. Use of saline drops and a bulb syringe to suction nares
Correct Answer: D
Rationale: For bronchiolitis due to RSV, saline drops and bulb syringe suctioning help clear nasal passages, improving breathing. Cough suppressants and antihistamines are not recommended as they may suppress necessary cough or cause sedation. Prophylactic treatment is not standard for family members unless immunocompromised, and breastfeeding should continue to provide antibodies.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.