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: 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: D

Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.

Correct Answer: A

Rationale: Correct Answer: A - Apply immobilization device after examination by physician Rationale: 1. Immobilization helps reduce pain and prevent further injury. 2. Physician examination ensures proper diagnosis and treatment plan. 3. Immobilization device may include chest binders or splints for support. 4. It is crucial to follow medical advice to prevent complications. Summary: B: Discouraging deep breaths can lead to respiratory complications. C: Advising against analgesics can increase pain and hinder recovery. D: Increased fluid intake is important but not directly related to rib fracture care.

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.

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: D

Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale: 1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer. 2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer. 3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.

Correct Answer: B

Rationale: The correct answer is B: Severe tenderness and swelling in the scrotum. Epididymitis is characterized by inflammation of the epididymis, causing symptoms such as severe tenderness and swelling in the scrotum. Choice A is incorrect as burning and pain on urination are more indicative of a urinary tract infection. Choice C, foul-smelling ejaculate and severe scrotal swelling, is not commonly associated with epididymitis. Choice D, foul-smelling urine and pain on urination, may indicate a urinary tract infection but are not specific to epididymitis.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.