Nokea
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
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Which of the following medications should the nurse identify as being incompatible with warfarin?
- A. Naproxen
- B. Metformin
- C. Lisinopril
- D. Albuterol
Correct Answer: A
Rationale: The correct answer is A: Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin, an anticoagulant. This is due to their combined effects on blood clotting. Metformin, Lisinopril, and Albuterol do not have a significant interaction with warfarin in terms of bleeding risk. Therefore, the nurse should identify Naproxen as incompatible with warfarin to prevent potential adverse effects.
The nurse should first notify the provider about------- followed by the-----------
- A. the fetal station and presentation
- B. frequency of uterine contractions
- C. green color of amniotic fluid
- D. history of gestational diabetes
- E. cervical dilation of 4 cm
Correct Answer: C
Rationale: The green color of amniotic fluid indicates meconium-stained fluid which can be a sign of fetal distress.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.
Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who has a prescription for compression stockings and did not receive them.
- B. A client who requests assistance in ambulating to the restroom.
- C. A client who ate 50% of their lunch tray.
- D. A client whose blood pressure is 88/52 mmHg.
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this vital sign reading to the nurse for further assessment and intervention to prevent complications such as hypoperfusion to vital organs. Choices A, B, and C do not pose immediate life-threatening risks and can be addressed during routine care. Choice D stands out as the priority due to the potential for serious consequences if not addressed promptly.
Which of the following instructions by the nurse is appropriate?
- A. Tighten your muscles before relaxing them when using muscle relaxation techniques
- B. Avoid deep breathing exercises, as they can increase stress.
- C. Focus on multiple thoughts at once to distract yourself from stress.
- D. Keep your emotions bottled up to maintain control over stress.
Correct Answer: A
Rationale: The correct answer is A because tightening muscles before relaxing them helps to enhance the effectiveness of muscle relaxation techniques by creating a greater sense of contrast between tension and relaxation. This sequence promotes deeper relaxation and can help reduce stress more effectively. Choice B is incorrect as deep breathing exercises are commonly used to reduce stress and promote relaxation. Choice C is incorrect as focusing on multiple thoughts at once can increase stress and overwhelm the individual. Choice D is incorrect as bottling up emotions can lead to increased stress and negatively impact mental health.