1. A nurse is caring for a patient who has a history of chronic obstructive

pulmonary disease (COPD) and is experiencing an acute exacerbation.

The nurse notices that the patient's oxygen saturation is 88% on room air.

What should the nurse do first? Explain your answer using the nursing

process.

- The nurse should first assess the patient's respiratory status, including

rate, depth, rhythm, use of accessory muscles, and breath sounds. This is

the first step of the nursing process and will help the nurse to identify the

patient's problem and prioritize interventions. The nurse should not

intervene without a proper assessment, as this could cause harm or delay

appropriate care.

2. A nurse is reviewing the laboratory results of a patient who has been

admitted with severe dehydration. The nurse notes that the patient's serum

sodium level is 160 mEq/L, serum potassium level is 3.2 mEq/L, and

blood urea nitrogen (BUN) level is 40 mg/dL. What are the possible

causes and complications of these findings? How would the nurse plan

and implement care for this patient?

- The possible causes of these findings are excessive fluid loss, inadequate

fluid intake, or increased sodium intake. The complications of these

findings are cellular dehydration, neurological impairment, cardiac

dysrhythmias, and renal failure. The nurse would plan and implement care

for this patient by monitoring vital signs, neurological status, cardiac

rhythm, urine output, and fluid balance; administering intravenous fluids

as prescribed; and educating the patient on the importance of hydration

and sodium restriction.

3. A nurse is preparing to administer an intramuscular injection of

penicillin to a patient who has a severe infection. The nurse checks the

patient's medication history and notes that the patient has a documented

allergy to penicillin. What should the nurse do next? How would the nurse

apply critical thinking skills to this situation?

- The nurse should next notify the provider of the patient's allergy and

request a different antibiotic. The nurse should also document the allergy

and the communication with the provider in the patient's chart. The nurse

would apply critical thinking skills to this situation by recognizing a

potential error, acting quickly to prevent harm, communicating effectively

with the provider, and documenting accurately and thoroughly.

4. A nurse is conducting a health history interview with a patient who