Nokea
While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed?
- A. A urinary output >30 mL/hr
- B. An oxygen saturation of 88%
- C. A normal pulse with warm, dry, pink skin
- D. A narrowing pulse pressure with normal pulse
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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In view of the fact that most older adults take at least six prescription drugs, what are four nursing interventions that can specifically help prevent problems caused by multiple drug use in older patients?
- A. Medication reconciliation
- B. Patient education regarding side effects
- C. Regular review of medication regimens
- D. Monitoring for drug interactions
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.
How does client and family care differ for a client with an acute terminal illness versus a chronic terminal illness?
- A. Acute terminal illness requires immediate interventions,while chronic terminal illness focuses on long-term symptom management.
- B. Acute terminal illness involves less family involvement,while chronic terminal illness requires extensive support.
- C. No difference exists.
- D. Care depends solely on the client’s preferences.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?
- A. Increased anterior-posterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct Answer: A
Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, air trapping causes hyperinflation of the lungs, leading to an increase in the AP chest diameter known as barrel chest. This is a classic physical finding in patients with COPD due to chronic airway obstruction.
Explanation of other choices:
B: Decreased respiratory rate - In COPD, patients typically have an increased respiratory rate due to difficulty breathing.
C: Weight gain - Weight gain is not a typical finding in COPD and is more often associated with other medical conditions or lifestyle factors.
D: Productive cough with yellow sputum - While a productive cough is common in COPD, yellow sputum is more indicative of a bacterial infection rather than COPD alone.
A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
- A. The client is able to ambulate in the hall without dyspnea.
- B. The client has a respiratory rate of 24 breaths per minute.
- C. The client's oxygen saturation is 92%.
- D. The client has a productive cough.
Correct Answer: A
Rationale: The correct answer is A because the ability to ambulate without dyspnea indicates effective oxygen therapy. When a client can move without experiencing difficulty breathing, it suggests that the oxygen therapy is adequately supporting their oxygenation needs. In contrast, options B, C, and D do not directly indicate the effectiveness of oxygen therapy. Option B (respiratory rate of 24 breaths per minute) may be within normal range but does not confirm the therapy's efficacy. Option C (oxygen saturation of 92%) is below the desired range of 95-100%, indicating inadequate oxygenation. Option D (productive cough) is unrelated to the assessment of oxygen therapy effectiveness.