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 .

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Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice b. “Curling’s ulcer.”

Choice A rationale:

Elevated blood pressure is not a common complication specifically associated with partial-thickness burns. It may occur due to pain or stress but is not the most critical complication to anticipate.

Choice B rationale:

Curling’s ulcer, a type of stress ulcer, is a significant complication that can develop in burn patients due to the stress response and reduced blood flow to the gastrointestinal tract.

Choice C rationale:

Compartment syndrome is more commonly associated with circumferential full-thickness burns rather than partial-thickness burns.

Choice D rationale:

Excruciating pain is a symptom rather than a complication. While pain management is crucial, it is not the most critical complication to anticipate.

A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. B. Institute droplet precautions, place the client in a private room, and keep the door closed. C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. D. Place the nasal swab specimen for COVID-19 directly into a biohazard bag.

Correct Answer is ["B"]

Explanation

The correct answer is Choice B.

Choice A rationale: While notifying the charge nurse about the client’s condition is important, it is not the most critical action. The charge nurse’s role would be to coordinate care and ensure appropriate resources are available, but the immediate safety and well-being of the client and others in the facility is the priority. Therefore, this choice is not the most important action for the nurse to take.

Choice B rationale: Instituting droplet precautions, placing the client in a private room, and keeping the door closed is the most important action. COVID-19 is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Therefore, it is crucial to implement droplet precautions to prevent the spread of the virus. This includes wearing a mask, eye protection, and a gown and gloves when caring for the client. The client should also be placed in a private room with the door closed to further prevent the spread of the virus.

Choice C rationale: While it is important for the client to inform others that they may have been potentially exposed, this is not the most critical action. The priority is to prevent the spread of the virus within the healthcare facility. Once the client is appropriately isolated and precautions are in place, the client can be educated and assisted with notifying others about potential exposure.

Choice D rationale: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a standard procedure when collecting specimens for testing. However, this action does not address the immediate need to prevent the spread of the virus within the healthcare facility. Therefore, this choice is not the most important action for the nurse to take.

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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

The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

Correct Answer is B

Explanation

Four days after exposure to the coronavirus (COVID-19), a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough, and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

Correct Answer is ["B"]

Explanation

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