Nokea
A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?
- A. Apply oxygen, as prescribed
- B. Assess and rate the chest pain
- C. Apply compression stockings
- D. Prepare for ventilation-perfusion scan
Correct Answer: A
Rationale: Based on the client's symptoms, the nurse suspects pulmonary embolism (PE). Emergency intervention is required to decrease the client's risk for death; therefore, the priority intervention is the application of oxygen. Although managing the client's pain is important this is not the priority intervention. The client may be prescribed a ventilation-perfusion scan and pulmonary angiography but these actions are not the priority interventions by the nurse. Application of compression stockings is ideal for preventing pulmonary emboli in high-risk clients but not an appropriate intervention after occurrence.
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Which action should the nurse take first when providing care for a client during an acute asthma attack?
- A. Send for STAT chest x-ray
- B. Obtain arterial blood gases (ABGs)
- C. Administer prescribed short-acting bronchodilator
- D. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes
Correct Answer: C
Rationale: Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.
What are the condition(s) that make up Virchow's triad? Select all that apply.
- A. Hypercoagulability
- B. Disruption of the vessel lining
- C. Hypocoagulability
- D. Edema
- E. Venostasis
Correct Answer: A,B,E
Rationale: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad.
The nurse is caring for a client diagnosed with bronchiectasis. Which is a primary nursing intervention in caring for this client?
- A. Postural drainage
- B. Droplet precautions
- C. Preventative antibiotic use
- D. Administration of antitussives
Correct Answer: A
Rationale: Management of bronchiectasis focuses on postural drainage and the movement of secretions out of the dilated sacs of the bronchioles. Bronchiectasis is not contagious or spread through droplets. The presence of infection is treated with selective antibiotics, but long-term preventative treatment with antibiotics is not protocol. Suppressing the cough mechanism with use of antitussives would be counterproductive in the management of bronchiectasis.
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
- A. Emergency contacts
- B. IV fluids ordered
- C. General statement of the client's condition
- D. Detailed physical assessment
Correct Answer: C
Rationale: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. The nurse would not document emergency contacts or a detailed physical assessment. The nurse would document the IV fluids running and not any that are ordered.
What is the reason for chest tubes after thoracic surgery?
- A. Draining secretions, air, and blood from the thoracic cavity
- B. Allowing air into the pleural space
- C. Indicating when the lungs have re-expanded by ceasing to bubble
- D. Draining secretions and blood while allowing air to remain in the thoracic cavity
Correct Answer: A
Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. Allowing air into the pleural space, indicating when lungs have re-expanded, and draining secretions and blood while air remains in the thoracic cavity are not the reasons for chest tubes after thoracic surgery.