Nokea
A client has sudden, severe pain in his back and chest, accompanied by shortness of breath. The client describes the pain as a 'tearing' sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is:
- A. Cardiac tamponade
- B. Stroke
- C. Pulmonary edema
- D. Myocardial infarction
Correct Answer: A
Rationale: A dissecting aortic aneurysm can rupture into the pericardial space, causing cardiac tamponade, a life-threatening complication requiring emergency intervention (hence the code cart). Stroke, pulmonary edema, and myocardial infarction are less common or indirect complications.
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The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses/treats bleeding, blood products (C) address hypovolemia, and Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention, not immediate.
The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every four hours while awake the client should use:
- A. Lemon-glycerin swabs.
- B. A commercial mouthwash.
- C. A saline or baking soda solution.
- D. A commercial toothpaste and brush.
Correct Answer: C
Rationale: Mucositis in leukemia clients requires gentle oral care to prevent infection and promote healing. Saline or baking soda solution is soothing and non-irritating. Lemon-glycerin swabs can dry the mucosa, commercial mouthwash may irritate, and brushing may cause trauma.
A Stage II pressure ulcer is characterized by:
- A. Redness in the involved area.
- B. Muscle spasms in the involved area.
- C. Pain in the involved area.
- D. Tissue necrosis in the involved area.
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:
- A. Open and dilate blocked coronary arteries.
- B. Assess the extent of arterial blockage.
- C. Bypass obstructed vessels.
- D. Assess the functional adequacy of the valves and heart muscle.
Correct Answer: B
Rationale: Cardiac catheterization in unstable angina assesses the extent of coronary artery blockage to guide interventions like angioplasty or bypass surgery.
The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.