The nurse is caring for a patient who is dyspneic with accessory muscle use, respiratory rate 24 breaths/minute, pulse oximetry 88% on room air, and speaking in phrases. When choosing an oxygen delivery system, which guideline is the most appropriate?

Always use a low flow device such as a nasal cannula or simple face mask.

Correct the PaO2 to a normal level as quickly as possible using mechanical ventilation.

Use continuous positive airway pressure (CPAP) to maintain PaCO2 greater than 50 mmHg.

Increase the PaO2 to an acceptable level at the lowest oxygen concentration possible.

Answer and Explanation

The Correct Answer is D

Choice A reason: Always using a low flow device such as a nasal cannula or simple face mask is not necessarily appropriate for all patients. The choice of device should be based on the patient's oxygen needs and clinical status.

Choice B reason: Correcting the PaO2 to a normal level as quickly as possible using mechanical ventilation is not appropriate in most cases. Rapid correction of oxygen levels can lead to complications such as oxygen toxicity. Mechanical ventilation is used in severe cases but is not the first line of treatment for most patients.

Choice C reason: Using continuous positive airway pressure (CPAP) to maintain PaCO2 greater than 50 mmHg is incorrect. CPAP is used to maintain open airways and improve oxygenation but is not used to target specific PaCO2 levels.

Choice D reason: Increasing the PaO2 to an acceptable level at the lowest oxygen concentration possible is the most appropriate guideline. This approach aims to correct hypoxemia without causing oxygen toxicity. The goal is to achieve adequate oxygenation while minimizing the risk of adverse effects from high oxygen concentrations.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Candidiasis, or oral thrush, is a common side effect of inhaled corticosteroids like budesonide. Patients should be educated on the importance of rinsing their mouth after using the inhaler to reduce the risk of this fungal infection.

Choice B reason: Dysphonia, or hoarseness, is another potential side effect of budesonide inhalers. This occurs due to the medication's effect on the vocal cords and can be minimized by using a spacer and rinsing the mouth after inhalation.

Choice C reason: Weight loss is not a common side effect of inhaled budesonide. Inhaled corticosteroids typically do not affect body weight in the same way that systemic corticosteroids might.

Choice D reason: Headache is a potential side effect of budesonide inhalers. Patients should be informed about this possibility and advised to manage headaches with appropriate over-the-counter medications if needed.

A. "I will adhere to my medication regimen even when I am not experiencing symptoms." B. "I will maintain regular physical activity and exercise with planned rest periods." C. "I will soak in a hot bath every night to help with muscle weakness and fatigue." D. "I will identify strategies to control anxiety and physical stress to prevent exacerbations."

Correct Answer is C

Explanation

Choice A reason: Adhering to the medication regimen even when not experiencing symptoms is crucial for managing multiple sclerosis (MS). MS is a chronic condition that requires consistent treatment to prevent relapses and slow disease progression. This statement indicates proper understanding of medication adherence.

Choice B reason: Maintaining regular physical activity and exercise with planned rest periods is important for managing MS. Physical activity helps maintain muscle strength, flexibility, and overall health, while planned rest periods prevent overexertion and fatigue. This statement indicates proper understanding of balancing activity and rest.

Choice C reason: Soaking in a hot bath every night to help with muscle weakness and fatigue requires further teaching. Heat can exacerbate MS symptoms, leading to increased fatigue and muscle weakness. Patients with MS are often advised to avoid hot baths and instead use cool or lukewarm water for comfort. This statement indicates a misunderstanding of how to manage symptoms effectively.

Choice D reason: Identifying strategies to control anxiety and physical stress to prevent exacerbations is important for managing MS. Stress can trigger MS relapses and worsen symptoms. Developing stress management techniques helps reduce the risk of exacerbations. This statement indicates proper understanding of the importance of stress management.

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The nurse is caring for a patient who is dyspneic with accessory muscle use, respiratory rate 24 breaths/minute, pulse oximetry 88% on room air, and speaking in phrases. When choosing an oxygen delivery system, which guideline is the most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient, newly diagnosed with chronic obstructive pulmonary disease (COPD), who has an order for a budesonide inhaler. When planning medication teaching, the nurse will plan to include which potential side effects of this medication? (Select All That Apply)

Correct Answer is ["A","B","D"]

Explanation

The nurse is teaching a patient with a new diagnosis of multiple sclerosis (MS) about self-care with this condition. What patient statement indicates to the nurse that the patient requires further teaching?

Correct Answer is C

Explanation

The nurse is providing discharge education to a patient with iron deficiency anemia. The patient has been prescribed to take an oral iron supplement. What will the nurse include in the teaching for this patient? (Select All That Apply)

The nurse is assessing a patient who is diagnosed with inflammatory bowel disease and is requiring inpatient treatment at a hospital. What medication will the nurse provide when caring for this patient?

The nurse is caring for a patient receiving chemotherapy who is admitted with an absolute neutrophil count (ANC) of 459 cells/ulu. The healthcare provider orders G-CSF (filgrastim). Which action will the nurse take to promote safe and effective use of filgrastim for this patient?

The nurse is caring for a patient with diabetes who presents with a hyperglycemic emergency. The patient's lab values are in the chart below. Which healthcare provider's (HCP) order will the nurse implement?

The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

The nurse is initiating Total Parenteral Nutrition (TPN) to a postoperative patient after a proctocolectomy. What actions will the nurse initiate to begin this therapy when caring for this patient?