Nokea
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
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The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Anticipate ear pain and give acetaminophen as needed
- B. Educate parents to expect the child to develop bad breath postoperatively
- C. Encourage the child to drink cold liquids through a straw
- D. Notify the health care provider about frequent, increased swallowing
- E. Use an oral suction device regularly to remove secretions from the back of the throat
Correct Answer: A,B,D
Rationale: Ear pain is common post-tonsillectomy due to referred pain, treated with acetaminophen. Bad breath is expected from healing tissue. Frequent swallowing may indicate bleeding, requiring provider notification. Cold liquids are soothing but straws risk trauma. Routine suctioning is unnecessary and risky.
When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?
- A. Tachycardia, blurred vision, hypotension, anorexia
- B. Orthostatic hypotension, vertigo, reactions to tyramine-rich foods
- C. Diarrhea, dry mouth, weight loss, reduced libido
- D. Photosensitivity, seizures, edema, hyperglycemia
Correct Answer: C
Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct Answer: B
Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.
An adult client who is ambulating in the corridor with the nurse becomes dizzy and faint. What should the nurse do at this time?
- A. Have her put her head between her legs
- B. Quickly go to get help
- C. Guide her to a chair in the corridor and ease her into it
- D. Encourage the client to walk faster
Correct Answer: C
Rationale: Guiding the client to a chair prevents falls and ensures safety during dizziness. Head positioning, seeking help, or faster walking are unsafe or impractical.
The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.