An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client “looks like he is having difficulty getting air.” What should the nurse’s initial action be?

Correct Answer: C

Rationale: The correct initial action for the nurse is to choose option C: Notify the physician. Increasing oxygen without a healthcare provider's order can be harmful, especially in COPD patients prone to retaining carbon dioxide. The nurse should communicate the situation to the physician to assess the client's condition and adjust the oxygen therapy appropriately. Option A is incorrect as it neglects the potential risks of high oxygen levels. Option B is incorrect as immediate decrease without proper assessment can be dangerous. Option D is not the priority when the client's oxygen therapy needs evaluation.

Correct Answer: B

Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.

Correct Answer: A

Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Correct Answer: A

Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively. B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: A

Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications. A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect. C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting. D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.

Correct Answer: D

Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT. Rationale: A) RBC count: AZT can cause anemia, not specifically affecting the RBC count. B) Serum calcium: AZT does not typically affect calcium levels. C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.