D455 Professional Nursing Role Transition - Set 3 - Part 2

Correct Answer: The current reading is acceptable for COPD

Option a is correct because the target oxygen saturation for clients with chronic obstructive pulmonary disease is eighty-eight to ninety-two percent, and ninety-four percent actually exceeds this target without requiring additional supplemental oxygen. Option b is incorrect because increasing oxygen to four liters per minute for a COPD client risks suppressing the hypoxic respiratory drive these clients rely on for breathing stimulation, potentially precipitating respiratory failure. Option c is incorrect because applying a non-rebreather mask delivers high-flow oxygen that is dangerous for COPD clients with carbon dioxide retention, as it could eliminate their hypoxic drive and cause respiratory arrest. Option d is incorrect because the client's oxygen saturation of ninety-four percent with comfortable breathing does not constitute a respiratory emergency requiring urgent respiratory therapy consultation or any immediate intervention.

Correct Answer: Practice using the incentive spirometer daily

Option d is correct because incentive spirometer use promotes lung expansion and teaches the breathing technique needed postoperatively, making preoperative practice essential for preventing pulmonary complications after thoracotomy surgery. Option a is incorrect because offering cigarette substitutes is not appropriate preoperative teaching content, and smoking cessation should be encouraged directly rather than through substitution products before major pulmonary surgery. Option b is incorrect because bed rest before surgery is contraindicated as it promotes deconditioning, increases venous stasis risk, and reduces the respiratory capacity the client will need for postoperative recovery. Option c is incorrect because avoiding all physical activity worsens the client's baseline functional status and contradicts the recommendation for maintained activity and early ambulation that supports better surgical outcomes overall.

Correct Answer: Maintain strict intake and output records

Option b is correct because urine output is the most sensitive indicator of organ perfusion in sepsis, and output below half a milliliter per kilogram per hour signals inadequate perfusion guiding critical fluid resuscitation decisions. Option a is incorrect because while capillary refill provides some perfusion information, it is less precise and reliable than urine output for continuously monitoring the effectiveness of sepsis treatment and ongoing fluid resuscitation. Option c is incorrect because blood cultures are obtained before antibiotic initiation to identify causative organisms but are not repeated every four hours as a routine monitoring parameter for ongoing sepsis treatment effectiveness. Option d is incorrect because assessing skin color once per shift is insufficient monitoring frequency during active sepsis management and provides less specific information about organ perfusion than strict intake and output tracking.

Correct Answer: Dark nail polish on the client's fingernails

Option c is correct because nail polish interferes with light transmission through the nail bed that pulse oximetry depends upon for accurate readings, potentially producing falsely low or unreliable oxygen saturation measurements. Option a is incorrect because a low-grade fever does not significantly affect the optical light transmission mechanism of pulse oximetry and would not cause the device to produce an inaccurate oxygen saturation reading result. Option b is incorrect because mild bruising on the back of the hand does not interfere with pulse oximetry accuracy since the sensor measures oxygen saturation through the fingertip capillary bed rather than the dorsal hand surface. Option d is incorrect because normal blood pressure indicates adequate peripheral perfusion, which actually supports accurate pulse oximetry readings rather than contributing to measurement errors or producing false low results.

Correct Answer: Metabolic alkalosis from acid loss

Option a is correct because persistent vomiting causes loss of hydrochloric acid from the stomach, shifting the body's acid-base balance toward alkalinity and resulting in metabolic alkalosis with potential tetany and cardiac complications. Option b is incorrect because respiratory acidosis results from inadequate ventilation and carbon dioxide retention related to pulmonary conditions rather than the gastrointestinal loss of hydrochloric acid through persistent vomiting. Option c is incorrect because metabolic acidosis involves bicarbonate loss or acid accumulation from conditions like diarrhea, renal failure, or diabetic ketoacidosis, not the hydrochloric acid loss that occurs with prolonged vomiting. Option d is incorrect because respiratory alkalosis results from excessive ventilation and carbon dioxide elimination, which may occur with anxiety or pain but is not the primary metabolic consequence of prolonged gastrointestinal vomiting.

Correct Answer: Determine the apical pulse rate and rhythm

Option c is correct because severe hypercalcemia causes shortened QT intervals and significantly increases the risk of fatal cardiac dysrhythmias, making cardiac assessment the most critical immediate nursing priority for client safety. Option a is incorrect because evaluating deep tendon reflexes provides information about neuromuscular function but does not address the most immediately life-threatening risk of cardiac dysrhythmias associated with critically elevated calcium levels. Option b is incorrect because measuring urine output is important for overall fluid balance monitoring but does not directly assess the most dangerous and immediate complication of severe hypercalcemia, which is cardiac rhythm disturbance. Option d is incorrect because Trousseau sign is an assessment for hypocalcemia rather than hypercalcemia, and performing this test would be clinically inappropriate and waste valuable time when cardiac monitoring is urgently needed.

Correct Answer: Serum calcium level

Option a is correct because numbness and tingling in the fingers and perioral area are classic early manifestations of hypocalcemia, often preceding more severe signs like Chvostek and Trousseau signs and tetany. Option b is incorrect because while potassium imbalances cause cardiac and muscular symptoms, the specific pattern of perioral and fingertip tingling is the hallmark presentation of hypocalcemia rather than potassium disturbance. Option c is incorrect because although magnesium deficiency can contribute to calcium imbalances, the described symptom pattern directly points to calcium as the primary electrolyte to evaluate before investigating contributing factors. Option d is incorrect because while phosphorus has an inverse relationship with calcium, the presenting symptoms are direct indicators of hypocalcemia, making calcium the appropriate first laboratory value to review immediately.

Correct Answer: Insulin with dextrose and calcium gluconate

Option d is correct because insulin with dextrose temporarily shifts potassium intracellularly to lower serum levels while calcium gluconate protects the myocardium from the dangerous cardiac effects of hyperkalemia shown on ECG. Option a is incorrect because while sodium bicarbonate may help shift potassium intracellularly, magnesium sulfate does not address hyperkalemia treatment, and this combination misses the critical cardiac protection provided by calcium administration. Option b is incorrect because administering oral potassium supplements to a client with peaked T-waves from hyperkalemia would dangerously worsen the already life-threatening potassium elevation and risk cardiac arrest. Option c is incorrect because while calcium provides cardiac protection, normal saline alone does not effectively reduce elevated potassium levels, and this combination lacks the intracellular potassium-shifting mechanism that insulin provides.

Correct Answer: Review the daily serum electrolyte results

Option b is correct because furosemide is a potassium-wasting loop diuretic, and reviewing electrolytes before administration ensures potassium levels are safe, preventing dangerous hypokalemia-induced cardiac dysrhythmias in this at-risk client. Option a is incorrect because while daily weight monitoring tracks fluid balance effectiveness, it does not identify the acute electrolyte depletion risk that makes pre-administration electrolyte review the more critical safety assessment. Option c is incorrect because while blood glucose monitoring is important for a diabetic client, the most dangerous immediate risk from furosemide administration is hypokalemia-related cardiac complications rather than glucose fluctuations. Option d is incorrect because while blood pressure provides useful hemodynamic information, the priority concern before administering a loop diuretic is potassium status since hypokalemia can cause life-threatening cardiac rhythm disturbances.

Correct Answer: Initiate seizure precautions immediately

Option a is correct because severe hyponatremia causes cerebral edema that significantly increases seizure risk, and implementing seizure precautions prevents injury from potential neurological complications before other treatments take effect. Option b is incorrect because while fluid restriction is an important treatment for SIADH and dilutional hyponatremia, it does not immediately protect the client from injury caused by seizures resulting from critically low sodium. Option c is incorrect because administering hypertonic saline addresses the underlying sodium deficit but takes time to correct levels, and protecting the client from seizure-related injury must take immediate precedence over treatment initiation. Option d is incorrect because monitoring urine specific gravity provides useful data about the concentration of urine output but does not directly protect the client from the immediate injury risk of seizures from hyponatremia.

Correct Answer: Offer the client ice chips for comfort

Option d is correct because a client with suspected bowel obstruction must remain nothing by mouth to prevent worsening the obstruction and potential aspiration, making ice chips contraindicated despite providing temporary comfort. Option a is incorrect because nasogastric tube insertion is an indicated intervention for bowel obstruction that provides gastric decompression, relieves nausea and vomiting, and reduces the pressure above the obstruction site. Option b is incorrect because semi-Fowler positioning is an indicated intervention that promotes comfort, facilitates breathing, and reduces aspiration risk for a client experiencing nausea and vomiting from bowel obstruction. Option c is incorrect because strict intake and output measurement is an indicated intervention essential for monitoring fluid balance, guiding intravenous fluid replacement, and assessing the effectiveness of decompression therapy.

Correct Answer: Withhold all food and fluid intake

Option b is correct because withholding food and fluids rests the pancreas by eliminating stimulation of pancreatic enzyme secretion, which is the cornerstone of acute pancreatitis management to prevent further organ damage. Option a is incorrect because even clear liquids stimulate pancreatic enzyme secretion and can worsen the inflammatory process during acute pancreatitis, making any oral intake inappropriate during the acute management phase. Option c is incorrect because offering meals of any type during acute pancreatitis stimulates the pancreas to produce digestive enzymes, directly contradicting the primary management goal of complete pancreatic rest during this phase. Option d is incorrect because total parenteral nutrition is reserved for prolonged cases where the client cannot resume oral intake for an extended period and is not the immediate first-line dietary intervention for acute pancreatitis.

Correct Answer: Cheese for protein and low residue

Option a is correct because cheese provides high-quality protein with low residue content, making it appropriate for active Crohn disease when the goal is a high-calorie, high-protein, and low-fiber diet. Option b is incorrect because orange juice is acidic and can irritate the inflamed gastrointestinal tract in active Crohn disease, potentially triggering cramping, diarrhea, and worsening of existing mucosal inflammation and symptoms. Option c is incorrect because raisins are dried fruits that are high in fiber and residue, which can exacerbate Crohn disease symptoms by increasing intestinal motility and irritating the inflamed gastrointestinal mucosa. Option d is incorrect because raw broccoli is a high-fiber cruciferous vegetable that produces gas and increases intestinal bulk, both of which aggravate active Crohn disease symptoms and should be avoided during flares.

Correct Answer: They neutralize acid in the stomach

Option c is correct because antacids work by chemically neutralizing existing hydrochloric acid in the stomach, providing rapid but temporary symptom relief, which distinguishes their mechanism from other reflux medications. Option a is incorrect because coating the esophageal lining describes the mechanism of sucralfate, which forms a protective barrier over mucosal surfaces, and this is not how antacids achieve their therapeutic effect on reflux symptoms. Option b is incorrect because slowing gastric emptying would actually worsen reflux by keeping acidic contents in the stomach longer, and this does not describe any antacid mechanism but rather an undesirable gastrointestinal effect. Option d is incorrect because decreasing gastric acid production describes the mechanism of proton pump inhibitors and histamine-two receptor blockers rather than antacids, which only neutralize acid already present in the stomach.

Correct Answer: Use laxatives routinely to prevent constipation

Option d is correct because routine laxative use should be avoided as it causes bowel dependency, electrolyte imbalances, and disrupts normal peristalsis, which paradoxically increases rather than decreases future obstruction risk. Option a is incorrect because daily walking and physical activity promote healthy intestinal motility and are strongly recommended as lifestyle measures that help prevent bowel obstruction recurrence through natural peristalsis stimulation. Option b is incorrect because adequate hydration with at least eight glasses of water daily keeps stool soft, supports healthy bowel function, and is an appropriate evidence-based recommendation for preventing obstruction recurrence. Option c is incorrect because psyllium is a bulk-forming fiber supplement that promotes regular bowel movements without the dependency risks of stimulant laxatives and is an appropriate preventive measure for obstruction recurrence.

Correct Answer: Turn the client from side to side

Option b is correct because repositioning the client helps redistribute dialysate within the peritoneal cavity and can dislodge the catheter from omentum or tissue that may be blocking drainage, resolving the problem non-invasively. Option a is incorrect because catheter irrigation is a more invasive intervention that should be attempted only after simpler repositioning measures have failed to resolve the drainage issue during peritoneal dialysis treatment. Option c is incorrect because notifying the healthcare provider is appropriate if repositioning does not resolve the drainage problem, but the nurse should attempt the least invasive corrective measure before escalating the situation. Option d is incorrect because increasing dwell time does not address the drainage obstruction problem and could worsen fluid retention, abdominal distention, and blood pressure elevation by allowing additional fluid absorption.

Correct Answer: Identify it as requiring further education

Option d is correct because dark green vegetables and potatoes are high-potassium foods that must be limited in end-stage renal disease, and this statement demonstrates the client lacks understanding of necessary dietary restrictions. Option a is incorrect because reinforcing a high-potassium dietary plan in a client with renal disease who was just treated for hyperkalemia would be dangerous and could directly contribute to recurrence of life-threatening potassium elevation. Option b is incorrect because documenting this statement as meeting discharge goals would be inaccurate, as the client's plan to consume high-potassium foods contradicts the essential dietary restrictions for end-stage renal disease management. Option c is incorrect because while enthusiasm for healthy eating is positive, the specific food choices are medically inappropriate for this client's condition and represent a knowledge deficit rather than a normal recovery response.

Correct Answer: Daily weight decrease of two pounds

Option a is correct because furosemide is a diuretic prescribed to reduce fluid overload, and a daily weight decrease demonstrates successful fluid removal, which is the most direct indicator of pharmacological effectiveness. Option b is incorrect because while improved appetite may occur as the child feels better with decreased fluid overload, it is an indirect and subjective indicator rather than a direct measure of diuretic effectiveness. Option c is incorrect because while heart rate normalization may accompany improved fluid balance, it is influenced by many factors and is less specific than weight change for directly measuring diuretic medication effectiveness. Option d is incorrect because improved mood and playfulness reflect overall wellbeing improvement but do not specifically measure the intended pharmacological action of fluid removal that furosemide is prescribed to achieve.

Correct Answer: Hold the lisinopril and notify the provider

Option d is correct because ACE inhibitors like lisinopril cause potassium retention, and continuing the medication with critically elevated potassium would further worsen hyperkalemia and increase the risk of fatal cardiac dysrhythmias. Option a is incorrect because continuing lisinopril at the current dose when potassium is critically elevated ignores the medication's potassium-retaining effect and fails to address the immediate danger of worsening life-threatening hyperkalemia. Option b is incorrect because while potassium binders may be used in management, administering lisinopril alongside a binder does not eliminate the ACE inhibitor's ongoing contribution to dangerous potassium elevation in this clinical situation. Option c is incorrect because increasing the lisinopril dose would intensify potassium retention and dramatically worsen the already critically elevated potassium level, placing the client at even greater risk for cardiac arrest.

Correct Answer: Evaluate the client's mental status

Option b is correct because critically low sodium causes cerebral edema leading to confusion, altered consciousness, and seizure risk, making mental status evaluation the most important assessment for detecting dangerous neurological deterioration. Option a is incorrect because skin bruising assessment is relevant for coagulation disorders or thrombocytopenia rather than the electrolyte imbalances present in this client, and it does not address the urgent neurological risks of hyponatremia. Option c is incorrect because urine color observation provides limited information about the severity of sodium imbalance and does not assess the most dangerous complication of hyponatremia, which is neurological compromise and seizure risk. Option d is incorrect because measuring calf circumference assesses for deep vein thrombosis or peripheral edema, which are not the priority concerns when a client presents with critically low sodium and the risk of cerebral edema.