a nurse observes a client with chronic obstructive pulmonary disease copd who is struggling to breathe what should the nurse do first
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

2. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says 'Mine'. According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

Correct answer: A

Rationale: The correct answer is A: Autonomy vs. Shame and Doubt. In Erikson's theory, toddlers aged 1-3 years are in the Autonomy vs. Shame and Doubt stage. During this stage, children begin to assert their independence and control over their environment. The behavior of the hospitalized toddler holding a toy and saying 'Mine' demonstrates the child's developing sense of autonomy and ownership. Choices B, C, and D correspond to different stages in Erikson's theory: Industry vs. Inferiority (school-age children), Initiative vs. Guilt (preschoolers), and Trust vs. Mistrust (infants), respectively, which are not applicable to the behavior described.

3. A client with a diagnosis of hypothyroidism is prescribed levothyroxine (Synthroid). What is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The correct answer is C: 'Report any symptoms of hyperthyroidism.' Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate an excessive dose of levothyroxine and should be reported to the healthcare provider for proper adjustment of the medication. Choice A is incorrect because levothyroxine is usually taken in the morning on an empty stomach to maximize absorption. Choice B is incorrect because taking levothyroxine with food can interfere with its absorption. Choice D is incorrect because discontinuing levothyroxine abruptly can lead to a worsening of hypothyroidism symptoms.

4. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?

Correct answer: D

Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.

5. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?

Correct answer: B

Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.

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