A nurse is receiving morning report when an alarm notifies the nurse that a client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. The nurse immediately assesses the client, and finds the client resting comfortably in bed on 2 liters of supplemental oxygen via nasal cannula. The client denies distress. Which of the following is the most appropriate nursing action?

Continue to monitor the patient

Silence future alarms

Place the patient on a non-rebreather mask

Increase the oxygen to 4 liters per minute

Answer and Explanation

The Correct Answer is A

A.   The client is resting comfortably, denies distress, and has an oxygen saturation of 89% on 2 liters of supplemental oxygen. This is within an acceptable range for many patients with COPD. Given the client's current status, it is appropriate to continue monitoring the oxygen saturation and assess for any changes in condition.
B.   While the alarm may be annoying, it is important to keep it active to alert the nurse to any significant changes in the client's oxygen saturation.
C.   A non-rebreather mask delivers a higher concentration of oxygen and is typically used in more critical situations. In this case, the client's oxygen saturation is within a safe range, and there is no need to increase the oxygen delivery method.
D.   Increasing the oxygen to 4 liters per minute without a clear indication of need could lead to oxygen toxicity, especially in patients with COPD. It is important to titrate oxygen therapy to the lowest level that maintains adequate oxygen saturation.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Black, tarry stool is indicative of blood that has been digested in the upper GI tract. The dark color is due to the action of digestive enzymes on blood.
B. Clay-colored stool is typically associated with biliary obstruction, not upper GI bleeding.
C. Watery stool can be caused by various conditions, including infections, inflammatory bowel diseases, and medications. It is not a specific indicator of upper GI bleeding.
D. Bright red blood in the stool is more likely to be associated with lower GI bleeding, such as from hemorrhoids or anal fissures.

A. Check the client's most recent potassium level B. Administer a bolus of 1,000 mL of normal saline C. Administer potassium chloride intravenously (IV) D. Administer sodium polystyrene sulfonate (Kayexalate)

Correct Answer is A

Explanation

A. Peaked T-waves and a widened QRS complex on an ECG are often signs of hyperkalemia, which is an elevated potassium level in the blood. This can be a serious complication of acute kidney injury (AKI), especially in the oliguric phase when the kidneys are unable to effectively excrete potassium.A
B. While fluid management is important in AKI, administering a bolus of normal saline is not the first priority in the presence of suspected hyperkalemia. The primary concern is to address the electrolyte imbalance.

C. Administering potassium chloride would worsen hyperkalemia and should be avoided.
D. Kayexalate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the gastrointestinal tract. However, checking the potassium level is the first step in confirming the diagnosis and determining the appropriate treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting a stool specimen from a client. What stool characteristic indicates to the nurse that the client may have an upper gastrointestinal (GI) bleed?

Correct Answer is A

Explanation

A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

Correct Answer is A

Explanation

A nurse is assigned to care for a client on a medical-surgical unit. Exhibits Complete the following sentence by using the list of options. Based on the information provided, the client is likely experiencing which is caused by

A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

A client with multiple complaints has been referred to a neurologist for further evaluation. Which of the following complaints are common manifestations of amyotrophic lateral sclerosis? (Select all that apply.)

A nurse is caring for an 83-year-old client who asks for a warm blanket despite the room temperature being 80°F. The nurse understands that which of the following physiological changes experienced by older adults makes it more difficult for them maintain their body temperature?

An older adult client is brought to an urgent care clinic by her paid in-home caregiver for a suspected UTI. The client has bruising to the left side of her face and appears fearful when her caregiver makes sudden movements. Which priority action should the nurse take first?

The nurse is assisting while a neurologist administers an edrophonium (Tensilon) test to a client with facial weakness and ptosis. If the test is positive for myasthenia gravis, which outcome would the nurse observe?

A nurse is caring for a client who has a diagnosis of myasthenia gravis. When creating the nutritional plan of care for the client, which of the following foods would be appropriate to include?