Nokea
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.
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Reggie is a teenager suffering from osteomyelitis; the nurse would expect which of the following symptoms? Select all that apply.
- A. Fever
- B. Irritability
- C. Pallor
- D. Tenderness
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: During the Schilling test, which is used to evaluate the absorption of vitamin B12 in the gastrointestinal system, the essential nursing intervention is to collect urine samples 24-48 hours after the client has received nonradioactive B12. The test involves administering both radioactive and nonradioactive forms of vitamin B12 to the client. The client's ability to absorb the vitamin B12 is assessed by measuring the amount of labeled B12 in the urine over the specified time period. This helps in diagnosing conditions such as pernicious anemia or malabsorption of vitamin B12. Blood samples are not typically collected for this test, and allowing fluid consumption is important to keep the client hydrated. The client does not need to lie down in a specific position for an extended period following nonradioactive B12 administration.
Which action by the nurse demonstrates use of evidence-based practice (EBP)?
- A. Gathering equipment for a procedure
- B. Documenting changes in a patient's status
- C. Questioning the use of daily central line dressing changes
- D. Clarifying a physician's prescription for morphine
Correct Answer: C
Rationale: Questioning the use of daily central line dressing changes demonstrates the use of evidence-based practice (EBP) by the nurse. In EBP, decisions about patient care should be informed by the best available evidence, clinical expertise, and patient preferences. By questioning the necessity of daily dressing changes for central lines, the nurse is seeking to ensure that the care provided is based on sound evidence and best practices rather than simply following routine procedures. This critical thinking and questioning approach aligns with the principles of evidence-based practice.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
- A. Self-care deficient: Bathing/hygiene
- B. Dysfunctional grieving
- C. Ineffective cerebral tissue perfusion
- D. Risk for injury
Correct Answer: C
Rationale: The nursing diagnosis that takes the highest priority for a client in a late stage of AIDS with signs of AIDS-related dementia is Ineffective cerebral tissue perfusion. This diagnosis is prioritized because AIDS-related dementia is associated with changes in brain function due to HIV affecting the brain tissues. Ensuring adequate cerebral perfusion is crucial to maintaining brain function and preventing further deterioration. Monitoring and addressing any factors that could affect cerebral perfusion, such as blood pressure, oxygenation, and circulation, are essential in managing this condition. Other nursing diagnoses are also important, but addressing ineffective cerebral tissue perfusion should be the highest priority in this situation to prevent further complications related to neurological function.
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
- A. respiratory compromise related to inhalation of smoke
- B. pneumonia related to prolonged bedrest
- C. fat embolism syndrome related to femur fracture
- D. hypovolemic shock related to multiple trauma
Correct Answer: C
Rationale: The symptoms described in the scenario - dyspnea, tachypnea, crackles in lung fields, and coughing up thick, white sputum - are indicative of fat embolism syndrome (FES), which occurs as a complication of long bone fractures like the femur fracture in this case. FES is characterized by the release of fat droplets into the bloodstream, which can then travel to the lungs and cause respiratory distress. The onset of symptoms typically occurs within 24-72 hours after the initial injury, making it a likely cause for Ms. Slovenski's condition. This is a medical emergency that requires prompt recognition and intervention to prevent further complications. The other options (A, B, and D) do not align with the clinical picture presented in the scenario and are less likely causes of her current symptoms.