The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?

Elevate head of bed no higher than 30 degrees.

Affirm blood glucose is below 160 mg/dL (8.88 mmol/L)

Check for a stat intravenous diuretic prescription.

Obtain a manual blood pressure measurement.

Answer and Explanation

The Correct Answer is D

A pounding headache in a client with COPD may be a symptom of increased carbon dioxide (CO2) levels in the blood, known as hypercapnia. Hypercapnia can lead to vasodilation, resulting in headaches. In this situation, it is crucial to assess the client's blood pressure to determine if it is elevated, as this could be contributing to the headache.

Obtaining a manual blood pressure measurement allows for a more accurate assessment of the client's blood pressure compared to automated measurements. It is important to assess both systolic and diastolic blood pressures, as elevated blood pressure can worsen headaches and have other negative effects on the client's health.

Elevating the head of the bed no higher than 30 degrees is a general measure used to improve respiratory function in clients with COPD. However, in this specific situation, it may not directly address the pounding headache. Elevating the head of the bed can help reduce dyspnea and improve oxygenation, but it may not alleviate the headache caused by hypercapnia.

Affirming blood glucose levels are below 160 mg/dL (8.88 mmol/L) is not the primary concern in this case. While high blood glucose levels can have various effects on the body, including headaches, the priority is to assess the client's blood pressure due to the specific context of a COPD exacerbation.

Checking for a stat intravenous diuretic prescription is not necessary in response to the client's headache. Diuretics are typically used to remove excess fluid from the body and may not directly address the underlying cause of the headache in this situation.

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 C

Explanation

A) Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B) Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C) Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D) Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.

Correct Answer is ["0.3"]

Explanation

To calculate the mL of dalteparin to administer, we need to determine the total number

of units required for the client and then convert it to the volume based on the concentration provided.

First, we need to calculate the total number of units required: Weight of the client: 110 pounds

Dalteparin dosage: 150 units/kg Duration of treatment: 4 months

To convert the client's weight from pounds to kilograms, we divide it by 2.2: 110 pounds / 2.2 = 50 kilograms

Next, we calculate the total number of units required:

150 units/kg * 50 kilograms = 7,500 units

Now we can calculate the volume to administer:

7,500 units / 7,500 units/0.3 mL = 0.3 mL

Therefore, the nurse should administer 0.3 mL of dalteparin.

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

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Correct Answer is C

Explanation

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

Correct Answer is ["0.3"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?