Nokea
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
- A. Obtaining vital signs
- B. Inserting a nasogastric (NG) tube
- C. Asking the client about the precipitating events
- D. Completing an abdominal physical assessment
Correct Answer: A
Rationale: The priority action for the client with GI bleeding is to obtain vital signs to determine whether the client is in shock from blood loss and obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. A complete abdominal physical assessment must be performed but is not the priority. Insertion of an NG tube may be prescribed but is not the priority action.
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The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
- A. Rinsing the incision with sterile water after feeding
- B. Cleaning the incision only when serous exudate forms
- C. Rubbing the incision gently with a sterile cotton-tipped swab
- D. Replacing the Logan bar carefully after cleaning the incision
Correct Answer: A
Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision.
The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse should take which action first in the care of this wound?
- A. Prepare for suturing the area.
- B. Determine when the client last had a tetanus vaccine.
- C. Cleanse the wound by flushing with sterile normal saline.
- D. Apply direct pressure to the laceration to stop the bleeding.
Correct Answer: D
Rationale: In the presence of active bleeding from a scalp laceration, the priority is to control the bleeding to prevent further blood loss and stabilize the client. Applying direct pressure to the laceration is the most effective initial action to achieve this. Preparing for suturing, determining tetanus vaccine status, and cleansing the wound are important but secondary actions that follow after bleeding is controlled.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
- A. Equal bilateral chest expansion
- B. Respiratory rate of 22 breaths per minute
- C. Diminished breath sounds on the affected side
- D. Few scattered wheezes, unchanged from baseline
Correct Answer: C
Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for?
- A. Cyanosis with accompanying pallor
- B. Diffuse crackles and rhonchi on chest auscultation
- C. Increase in respiratory rate from 18 to 30 breaths per minute
- D. Haziness or 'white-out' appearance of lungs on chest radiograph
Correct Answer: C
Rationale: ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or 'white-out' appearance in the later stages.