Nokea
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply.
- A. Hypertension
- B. Flat neck veins
- C. Increased cyanosis
- D. Tracheal deviation to the right
- E. Diminished breath sounds on the left
- F. Observable asymmetry of the thorax
Correct Answer: C,D,E,F
Rationale: A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise.
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The nurse notes this cardiac rhythm on the cardiac monitor (refer to figure). What should the nurse interpret that the client is experiencing?
- A. Atrial fibrillation
- B. Sinus bradycardia
- C. Ventricular fibrillation (VF)
- D. Premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: PVCs are abnormal ectopic beats (occurring in otherwise normal sinus rhythm) originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. In atrial fibrillation, no definitive P wave usually can be observed; only fibrillatory waves before each QRS complex are observed. In sinus bradycardia, atrial and ventricular rhythms are regular, and the rates are less than 60 beats per minute. In ventricular fibrillation, impulses from many irritable foci in the ventricles fire in a totally disorganized manner, which appears as a chaotic rapid rhythm in which the ventricles quiver.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.
What should the pregnant client be taught to immediately eliminate in the first trimester to promote normal fetal organ development?
- A. Smoking
- B. Caffeine
- C. Alcohol
- D. Fatty foods
Correct Answer: C
Rationale: The first trimester, 'organogenesis,' is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this critical period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development. Although options 1, 2, and 3 may be concerns, they are not specifically associated with the first trimester of pregnancy.
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
A client hospitalized with a diagnosis of thrombophlebitis is being treated with heparin infusion therapy. About 24 hours after the infusion has begun, the nurse notes that the client's partial thromboplastin time (PTT) is 65 seconds with a control of 30 seconds. What nursing action should the nurse implement?
- A. Discontinue the heparin infusion.
- B. Prepare to administer protamine sulfate.
- C. Notify the primary health care provider of the laboratory results.
- D. Include in report that the client is adequately anticoagulated.
Correct Answer: D
Rationale: The effectiveness of heparin therapy is monitored by the results of the PTT. Desired range for therapeutic anticoagulation is 1.5 to 2.5 times the control. A PTT of 65 seconds is within the therapeutic range. Therefore, options 1, 2, and 3 are incorrect actions.