Question

Which client requires immediate intervention?

Answer 1

Correct Answers:

pH 7.29, PaCO2 70, HC0₃ 25

Rationale :

🫁 pH below 7.35 shows acidemia, and the PaCO₂ of 70 is critically high → indicates CO₂ retention.

🫁 This is uncompensated respiratory acidosis, often due to hypoventilation, COPD, or drug overdose.

🫁 If untreated, this can cause respiratory arrest, arrhythmias, and organ failure.

🫁 Requires immediate intervention such as airway support and provider notification.

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Answer 2

Correct Answers:

Notify the healthcare provider immediately

Rationale :

⚠️ Severe pain with rigidity, distension, and rebound tenderness strongly indicates peritonitis or intestinal perforation.

⚠️ This is a surgical emergency, as infection can spread quickly into the bloodstream causing sepsis and shock.

⚠️ Reassessing later wastes time, and applying heat may worsen bleeding or inflammation.

⚠️ Giving opioids before notifying the provider can mask symptoms and delay diagnosis.

⚠️ Priority: notify the provider immediately for urgent evaluation and intervention.

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Answer 3

Correct Answers:

Photosensitivity
Proteinuria
Butterfly-shaped facial rash
Joint pain and swelling

Rationale :

✅ Photosensitivity

🦋Clients with SLE often have an abnormal immune response to ultraviolet (UV) light, which triggers inflammation in the skin.

🦋Even brief sun exposure can cause rashes, worsening fatigue, and systemic flare-ups.

🦋This makes photosensitivity a hallmark feature of the disease, and clients are taught to avoid direct sun, wear protective clothing, and use sunscreen daily.

🦋Recognizing this sensitivity is essential for preventing symptom exacerbations and maintaining skin integrity.

✅ Proteinuria

🦋SLE commonly affects the kidneys in a condition called lupus nephritis, where immune complexes damage the glomeruli.

🦋This results in proteinuria (protein leaking into urine), which is a red-flag indicator of kidney involvement.

🦋Persistent proteinuria can lead to renal failure if not managed early with immunosuppressive therapy.

🦋Monitoring kidney function is critical because renal complications are a major cause of morbidity in SLE.

✅ Butterfly-shaped facial rash

🦋One of the most recognizable signs of SLE is the malar or “butterfly” rash, spreading across the cheeks and nasal bridge.

🦋The rash is usually erythematous (red), non-painful, and photosensitive.

🦋It is considered a classic diagnostic feature, often included in the American College of Rheumatology (ACR) diagnostic criteria for lupus.

🦋The appearance of this rash helps differentiate SLE from other autoimmune conditions.

✅ Joint pain and swelling

🦋Arthritis-like symptoms are very common in SLE, with clients experiencing joint pain, swelling, stiffness, and decreased mobility.

🦋Unlike rheumatoid arthritis, lupus arthritis is typically non-erosive, meaning it causes inflammation but not permanent joint deformities.

🦋Joint pain can significantly affect daily function and quality of life.

🦋Early recognition and treatment with NSAIDs or corticosteroids help control inflammation and improve comfort.

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Answer 4

Correct Answers:

pH 7.30
PaC0₂ 55 mmHg
Restlessness and headache

Rationale :

✅ pH 7.30

🌫️ A normal pH is 7.35–7.45.

🌫️ A pH of 7.30 is acidic, confirming the presence of acidosis.

🌫️ In COPD, poor ventilation causes retention of CO₂, which lowers the pH.

🌫️ This indicates the blood is too acidic and the body is unable to maintain normal balance.

🌫️ Detecting this early helps the nurse anticipate respiratory interventions such as oxygen titration, airway clearance, or even ventilatory support if worsening.

✅ PaCO₂ 55 mmHg

🌫️ The normal PaCO₂ (partial pressure of carbon dioxide) is 35–45 mmHg.

🌫️ A PaCO₂ of 55 mmHg is elevated, confirming that the client is retaining CO₂ due to hypoventilation.

🌫️ In COPD, chronic airway obstruction limits effective gas exchange, leading to CO₂ buildup.

🌫️ This is the hallmark of respiratory acidosis because the lungs are the source of the imbalance.

🌫️ Prolonged CO₂ retention worsens acidosis and depresses the central nervous system if not corrected.

✅ Restlessness and headache

🌫️ Neurological changes are early warning signs of hypercapnia (high CO₂ levels).

🌫️ Restlessness is often the first clue that oxygenation and acid–base balance are impaired, even before vital signs show changes.

🌫️ Headache occurs because CO₂ dilates cerebral blood vessels, increasing intracranial pressure.

🌫️ If unaddressed, symptoms can progress to confusion, drowsiness, and coma.

🌫️ Nurses must recognize these subtle changes early to prevent respiratory failure.

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Answer 5

Correct Answers:

Monitor for at least 4-6 hours for recurrence

Rationale :

👄Angioedema is sudden swelling of the skin, lips, tongue, or airway, often due to an allergic reaction or ACE inhibitor use.

👄Even after symptoms improve, there is a significant risk of recurrence, sometimes rapidly and without warning.

👄The greatest danger is airway obstruction, which can progress to respiratory arrest if not caught early.

👄Continuous monitoring in the ER or observation unit for 4–6 hours allows immediate intervention (e.g., epinephrine, airway support) if swelling returns.

👄Oral diphenhydramine and resuming diet may be part of follow-up care, but they are not as urgent as ensuring airway safety.

👄Discharging too soon places the client at risk of a delayed, possibly fatal reaction.

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Answer 6

Correct Answers:

"Addiction risk is the same for everyone."

Rationale :

🌺In hospice and end-of-life care, the priority is comfort, not addiction prevention.

🌺Morphine is the standard medication for severe cancer pain and dyspnea, helping to reduce suffering and improve quality of life.

🌺True addiction is not a concern in terminal illness, because the goal is not long-term use but relief of pain and distress.

🌺Non-drug measures are supportive, but they are not substitutes for severe pain relief in metastatic cancer.

🌺The nurse reassures the family that morphine use at this stage is appropriate, focusing on dignity and comfort in the client’s final days.

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Answer 7

Correct Answers:

Advise stopping over-the-counter supplements

Rationale :

♦️Taking many medications daily = polypharmacy, which increases the risk of drug-drug interactions, side effects, and confusion.

♦️The safest and most effective action is to review all medications (prescribed, OTC, and supplements) with the provider or pharmacist.

♦️Stopping medications or supplements without supervision can be unsafe.

♦️Taking all medications at once raises the risk of side effects and errors.

♦️This review helps optimize treatment, reduce unnecessary drugs, and improve the client’s safety and adherence.

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Answer 8

Correct Answers:

Stridor and drooling

Rationale :

📌Angioedema can affect the skin, mucosa, and most critically, the airway.

📌Stridor (a high-pitched sound when breathing) and drooling indicate upper airway obstruction due to tongue, pharyngeal, or laryngeal swelling.

📌This is a life-threatening emergency, as the airway can close rapidly, leading to respiratory arrest.

📌Facial swelling and itching on the chest are concerning, but they do not indicate imminent airway compromise like stridor and drooling do.

📌Immediate action: call rapid response, prepare for intubation, administer epinephrine and airway support

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Answer 9

Correct Answers:

Encourage the use of heat therapy and exercise

Rationale :

🦴Osteoarthritis (OA) is a degenerative joint disease characterized by chronic joint pain, stiffness, and decreased mobility.

🦴Non-pharmacological interventions like heat therapy help relax muscles, reduce stiffness, and relieve discomfort.

🦴Exercise (especially low-impact like walking, swimming, or stretching) improves joint flexibility, strengthens supporting muscles, and reduces long-term pain.

🦴Restricting mobility worsens stiffness and functional decline.

🦴Opioids are not first-line for chronic OA pain because of risks (dependence, sedation, constipation).

🦴Acetaminophen is actually considered one of the safest first-line medications for OA pain when used correctly, unless the client has significant liver disease.

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Answer 10

Correct Answers:

Monitor for non-verbal cues such as grimacing
Use FLACC scale for pain assessment
Administer PRN analgesics as ordered

Rationale :

✅ Monitor for non-verbal cues such as grimacing

💊Clients with advanced dementia may not be able to verbally express pain, but they often show it through facial expressions, body movements, or behaviors.

💊Cues such as grimacing, frowning, guarding, restlessness, or agitation are critical for identifying discomfort.

💊Nurses must observe closely and not rely only on verbal reports to guide pain management.

💊This proactive approach ensures timely recognition and intervention for pain.

✅ Use FLACC scale for pain assessment

💊The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for clients unable to self-report pain (infants, non-verbal adults, clients with cognitive impairment).

💊It provides an objective framework by assigning scores based on observable behaviors.

💊Using a validated tool increases the accuracy and consistency of pain assessments.

💊This ensures that pain is systematically measured and addressed.

✅ Administer PRN analgesics as ordered

💊 Explanation:

💊Once non-verbal cues and assessment tools indicate pain, the nurse should administer prescribed PRN (as needed) analgesics.

💊Pain relief in dementia is crucial because untreated pain may cause increased agitation, decreased mobility, poor nutrition, and reduced quality of life.

💊Following provider orders ensures safe, evidence-based pain control tailored to the client’s needs.

💊Nurses should also evaluate the effectiveness of analgesics afterward to guide ongoing care.

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QLexNursing

1 :
Which client requires immediate intervention?

2 :
A client reports severe abdominal pain rated 9/10. The abdomen is rigid, distended, and tender with rebound. What is the nurse's priority action?

3 :
Which findings are commonly associated with systemic lupus erythematosus ? (Select all that apply)

4 :
A client with COPD is at risk for respiratory acidosis. Which findings support this? (Select all that apply)

5 :
A client treated for angioedema in the ER is now stable. Which action is most important for the nurse?

6 :
A hospice client with metastatic cancer is moaning and restless despite morphine. Family worries that the morphine will cause addiction. What is the best response?

7 :
An 85-year-old client takes 12 prescribed medications daily. What is the nurse's best action?

8 :
Which assessment finding in a client with angioedema requires immediate action?

9 :
A 70-year-old client with osteoarthritis reports chronic pain. Which intervention is most appropriate?

10 :
Which interventions are appropriate for a non-verbal client with dementia in pain? (Select all that apply)

QLexNursing

1 : Which client requires immediate intervention?

2 : A client reports severe abdominal pain rated 9/10. The abdomen is rigid, distended, and tender with rebound. What is the nurse's priority action?

3 : Which findings are commonly associated with systemic lupus erythematosus ? (Select all that apply)

4 : A client with COPD is at risk for respiratory acidosis. Which findings support this? (Select all that apply)

5 : A client treated for angioedema in the ER is now stable. Which action is most important for the nurse?

6 : A hospice client with metastatic cancer is moaning and restless despite morphine. Family worries that the morphine will cause addiction. What is the best response?

7 : An 85-year-old client takes 12 prescribed medications daily. What is the nurse's best action?

8 : Which assessment finding in a client with angioedema requires immediate action?

9 : A 70-year-old client with osteoarthritis reports chronic pain. Which intervention is most appropriate?

10 : Which interventions are appropriate for a non-verbal client with dementia in pain? (Select all that apply)

1 :
Which client requires immediate intervention?

2 :
A client reports severe abdominal pain rated 9/10. The abdomen is rigid, distended, and tender with rebound. What is the nurse's priority action?

3 :
Which findings are commonly associated with systemic lupus erythematosus ? (Select all that apply)

4 :
A client with COPD is at risk for respiratory acidosis. Which findings support this? (Select all that apply)

5 :
A client treated for angioedema in the ER is now stable. Which action is most important for the nurse?

6 :
A hospice client with metastatic cancer is moaning and restless despite morphine. Family worries that the morphine will cause addiction. What is the best response?

7 :
An 85-year-old client takes 12 prescribed medications daily. What is the nurse's best action?

8 :
Which assessment finding in a client with angioedema requires immediate action?

9 :
A 70-year-old client with osteoarthritis reports chronic pain. Which intervention is most appropriate?

10 :
Which interventions are appropriate for a non-verbal client with dementia in pain? (Select all that apply)