a 64 year old male who has been diagnosed with copd and chf exhibits an increase in total body weight of 10 lbs over the last few days the nurse shoul
Logo

Nursing Elites

NCLEX-PN

Quizlet NCLEX PN 2023

1. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?

Correct answer: B

Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient's flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.

2. With a breech presentation, the nurse must be particularly alert for which of the following?

Correct answer: D

Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.

3. A client has been receiving cyanocobalamin (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?

Correct answer: D

Rationale: Cyanocobalamin is a B12 medication used for pernicious anemia. A reticulocyte count of 1% indicates the desired effect of the medication, as reticulocytes are immature red blood cells that increase in response to B12 therapy, improving anemia. Neutrophils, basophils, and monocytes are white blood cells and are not directly influenced by B12 injections, making them incorrect choices.

4. The nurse is caring for a client and wants to assess the neurologic function. Which of the following will give the most information?

Correct answer: A

Rationale: The correct answer is 'Level of consciousness.' Assessing the client's level of consciousness provides crucial information about their neurologic function, including subtle changes in verbal ability, orientation, and responsiveness to commands. Doll's eye reflex is a specific eye movement test used in neurologic assessments but may not provide as much comprehensive information as the client's overall consciousness level. The Babinski reflex is a test used to assess specific spinal cord function rather than overall neurologic function. Reaction to painful stimuli provides information about sensory function and pain response but may not offer as much insight into the client's neurologic status as assessing their level of consciousness.

5. A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min via nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?

Correct answer: A

Rationale: In clients with COPD and chronic respiratory acidosis, they are compensating for low oxygen and high carbon dioxide levels. Hypoxia acts as the main stimulus to breathe in individuals with chronic hypercapnia. When oxygen is administered, it can decrease the respiratory drive by eliminating the hypoxic drive and reducing the stimulus to breathe. Therefore, delivering oxygen at 1 L/min via nasal cannula helps prevent respiratory depression by maintaining the hypoxic drive to breathe. The other options are incorrect: COPD clients do not depend on a low carbon dioxide level as they are chronically hypercapnic, they do not retain hydrogen ions with high oxygen doses, and they do not thrive on a high oxygen level.

Similar Questions

A 28-year-old male has a diagnosis of AIDS. The patient has had a two-year history of AIDS. The most likely cognitive deficits include which of the following?
A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?
A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses