Nokea
What is the best intervention for a patient presenting with respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide humidified air
Correct Answer: A
Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.
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A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?
- A. Crackles in the lung bases
- B. Oxygen saturation of 95%
- C. Heart rate of 88/min
- D. Frequent productive cough
Correct Answer: A
Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.
A nurse is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum calcium level
- B. Blood glucose level
- C. Serum albumin level
- D. Serum sodium level
Correct Answer: C
Rationale: The correct answer is C, Serum albumin level. Monitoring the serum albumin level helps assess the nutritional effectiveness of total parenteral nutrition (TPN). Serum albumin is a protein that reflects the long-term nutritional status of a patient. Serum calcium level (choice A) is not directly related to TPN effectiveness. Blood glucose level (choice B) is important to monitor in diabetic patients but is not the primary indicator of TPN efficacy. Serum sodium level (choice D) is more related to fluid balance and electrolyte status rather than the effectiveness of TPN.
A nurse is caring for a client with deep vein thrombosis who is prescribed warfarin. Which of the following client statements indicates a need for further teaching?
- A. I will avoid vitamin K-rich foods.
- B. I will avoid using aspirin while on this medication.
- C. I will monitor my blood pressure regularly.
- D. I will increase my intake of leafy greens.
Correct Answer: D
Rationale: The correct answer is D. Warfarin's effectiveness is reduced by high intake of vitamin K-rich foods, so increasing their intake would contradict the treatment plan. Choices A, B, and C are all appropriate statements for a client on warfarin therapy. Avoiding vitamin K-rich foods helps maintain the medication's effectiveness, avoiding aspirin reduces the risk of bleeding, and monitoring blood pressure is essential for overall health monitoring.
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?
- A. Oxygen saturation of 91%
- B. Use of pursed-lip breathing
- C. Productive cough with green sputum
- D. Decreased breath sounds in the right lower lobe
Correct Answer: D
Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention.
Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.