Nokea
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
- A. Maintain circulation
- B. Manage pain
- C. Prepare the client for emergency surgery
- D. Teach postoperative breathing exercises
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
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In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.
What should the nurse include in the care plan for a client with a spinal cord injury?
- A. Frequent repositioning.
- B. High-protein diet.
- C. Limited mobility exercises.
- D. Fluid restriction.
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in clients with spinal cord injuries.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
- A. Normal breath sounds.
- B. Prolonged inspiration.
- C. Normal chest movement.
- D. Coarse crackles and rhonchi.
Correct Answer: D
Rationale: COPD exacerbation with infection produces coarse crackles and rhonchi from secretions and airway inflammation. Breath sounds are diminished, expiration is prolonged, and chest movement is reduced.
A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
- A. PaCO2.
- B. HCO3.
- C. PaO2.
- D. pH
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.
A client with a below-knee amputation is learning to wrap the residual limb. Which technique should the nurse teach?
- A. Wrap loosely to allow air circulation.
- B. Apply the wrap from proximal to distal.
- C. Use a figure-eight pattern.
- D. Secure the wrap with adhesive tape.
Correct Answer: C
Rationale: A figure-eight pattern ensures even pressure and proper shaping for prosthetic fitting.