A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

The client’s oxygen saturation level is 85%.

The client is eating less than half of meals

The client’s heart rate is 110 beats per minute.

The client is reading a book.

The client’s blood pressure is 160/90 mmHg.

Answer and Explanation

Correct Answer : A,C,E

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Assigning a client who is one day postoperative for a laparoscopic cholecystectomy to the practical nurse (PN) is appropriate. This procedure is minimally invasive, and the client is likely stable, requiring routine postoperative care such as wound assessment, pain management, and monitoring for any signs of complications.

Choice B rationale:

An older client who is one day postoperative with a colostomy for colon cancer may have complex postoperative needs, including colostomy care, monitoring for complications, and pain management. This level of care is usually within the scope of the registered nurse (RN) rather than a practical nurse (PN).

Choice C rationale:

An older adult who is scheduled for foot amputation due to diabetes complications is likely to have complex care needs, including wound care, diabetes management, and potential complications. This client would require the expertise of an RN rather than a PN.

Choice D rationale:

An adult with alcoholism, cirrhosis, and hepatic encephalopathy may have complex medical and psychosocial issues that require specialized nursing care. This client's condition is not appropriate for a practical nurse (PN) to manage, and the care should be provided by an RN or other specialized healthcare provider.

A. "MDD is less severe than dysthymia but lasts for at least 2 years.". B. "Dysthymia is characterized by alternating episodes of mania and depression.". C. "Unlike MDD, dysthymia does not impair social or occupational functioning.". D. "Dysthymia is chronic and lasts for at least 2 years, but is less severe than MDD.". E. Anxiety.

Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.

Choice B rationale:

This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.

Choice C rationale:

This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.

Choice D rationale:

This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

Correct Answer is D

Explanation

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

A nurse is teaching a client with hypertension about antihypertensive drugs. Which of the following statements by the client indicates an understanding of the teaching?