Nokea
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
You may also like to solve these questions
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
- A. Administering insulin once per day
- B. Administering multiple doses of insulin
- C. Limiting dietary fat intake
- D. Substituting an oral antidiabetic agent for insulin
Correct Answer: B
Rationale: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
A client with chronic obstructive pulmonary disease, who has been receiving mechanical ventilation for the past 5 days, expresses to a nurse his desire to have treatment withdrawn. Which statement about the client's legal rights is true in this situation?
- A. The nurse's assessment of the client and communication with the family guides the decision-making process.
- B. The nurse is an advocate for the client and should encourage the client to accept his current treatment regimen.
- C. The health care team must follow the treatment plan that was already established with client and family input.
- D. The client has the right to refuse treatment at any time.
Correct Answer: D
Rationale: Health care professionals must ensure a health care ethic that respects the role of the client in the decision-making process. According to the Patient's Bill of Rights, the client has the right to make decisions about his care at any time. The nurse should be a client advocate and be supportive of the decision he made.
The nurse is caring for an older client who insists on having a 'hot toddy' laced with liquor at bedtime to help her sleep. How should the nurse respond in order to give culturally sensitive and appropriate care?
- A. Is that something you learned from a relative or a friend?'
- B. No one your age should be drinking at bedtime.'
- C. That is an old wives' tale. The doctor can prescribe a sleep aid if you need one.'
- D. We don't allow alcohol in the hospital.'
Correct Answer: A
Rationale: Exploring the cultural or personal significance of the hot toddy shows respect, fostering culturally sensitive care.
A 65-year-old prostate cancer.
- A. A 47-year-old with Meniere's disease complaining of feeling dizzy.
- B. A 72-year-old with Alzheimer's disease complaining of disliking his home attendant.
- C. A 32-year-old with history of fall complaining of vomiting upon waking in the morning.
Correct Answer: D
Rationale: Vomiting after a fall may indicate a head injury, requiring immediate medical evaluation.
An adult is admitted for surgery for a secreting adrenal tumor. In the immediate postoperative period, which nursing action will be highest priority?
- A. Clear liquids as tolerated
- B. Administration of adrenal hormones as ordered
- C. Turn, cough, and deep breathe every two hours
- D. Administration of pain medication as ordered
Correct Answer: B
Rationale: Adrenal tumor resection may cause adrenal insufficiency; administering adrenal hormones is critical to replace deficient cortisol, preventing crisis. Liquids, breathing exercises, and pain management are secondary.