Nokea
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
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At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.
The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?
- A. Asymmetrical chest expansion and decreased breath sounds on the left
- B. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg)
- C. Client complains of 6/10 pain at the needle insertion site
- D. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min
Correct Answer: A
Rationale: Asymmetrical chest expansion and decreased breath sounds (A) suggest pneumothorax, a serious post-thoracentesis complication. Hypotension (B), pain (C), and mild tachypnea (D) are less urgent or expected.
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection