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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Correct Answer is A

Explanation

A. Chemotherapy often requires multiple infusions over a long period, and a CVAD provides a reliable and convenient access point for these treatments. It allows for the continuous or intermittent administration of chemotherapy drugs, which are often irritating to veins and require precise dosing.
B. While CVADs are used for administering chemotherapy and other treatments, they are not typically used to implant radioactive material for internal radiation (brachytherapy).
C. While CVADs reduce the need for repeated venipunctures and can help manage the complications of frequent injections, they do not eliminate the risk of infection. CVADs can themselves become a source of infection if not properly maintained, as they are open to the external environment.
D. The placement of a CVAD does not directly affect the side effects of chemotherapy, such as nausea and vomiting. The CVAD’s role is primarily related to the administration of medications and access to blood vessels.

A. Casts in the urine B. Dark, tarry stool C. Jaundice D. Pain in the left upper quadrant

Correct Answer is C

Explanation

A. Casts in the urine are typically associated with kidney problems, such as glomerulonephritis or kidney infections, rather than biliary obstruction. Casts are formed from proteins or cells in the renal tubules and are not related to bile duct obstruction or cholelithiasis.
B. Dark, tarry stools are indicative of upper gastrointestinal bleeding and the presence of digested blood in the stool. This condition, known as melena, is not typically associated with obstruction of the common bile duct due to cholelithiasis.
C. Jaundice is a common and significant finding in cases of obstruction of the common bile duct due to cholelithiasis. When the bile duct is obstructed, bilirubin, which is a component of bile, accumulates in the bloodstream because it cannot be properly excreted into the intestine.
D. Pain from cholelithiasis (gallstones) typically occurs in the right upper quadrant, not the left. The right upper quadrant pain is often associated with gallbladder inflammation or bile duct obstruction.

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Naxlex Comprehensive Predictor Exams

A client who will be undergoing chemotherapy and internal radiation for cancer treatment asks the nurse why they are scheduled for the placement of a central venous access device (CVAD). Which of the following is a benefit of placing a CVAD for someone who will be undergoing cancer treatment?

Correct Answer is A

Explanation

A client is admitted to the hospital with a diagnosis of obstruction of the common bile duct due to cholelithiasis. Which of the following assessment findings are consistent with this diagnosis?

Correct Answer is C

Explanation

A client with age-related macular degeneration (AMD) is undergoing photodynamic therapy with the medication Verteporfin. What should the nurse include in the discharge teaching for this client?

A nurse is caring for a patient with a diagnosis of sepsis who is on a ventilator in the intensive care unit. To reduce the risk of developing a physiologic stress ulcer, the nurse should anticipate an order to administer which medication?

A nurse is providing discharge education to a client who has undergone extracapsular cataract extraction surgery. What should the nurse include in the discharge teaching? (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?

A nurse is assessing a client who has chronic kidney disease and notes that the client has small crystals on his forehead. The nurse understands that this manifestation is a result of an excess of which substance in the body?

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 is admitted to the hospital with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). Which finding is consistent with known risk factors for this disease?