Nokea
A client is brought to the ED following a drowning event. The nurse assigned to the client understands that which is true regarding drowning?
- A. Drowning in very cold water causes a worse outcome for the client than drowning in warmer water.
- B. Aspiration of both salt and fresh water increases surfactant in the lungs and leads to increased lung compliance.
- C. If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment.
- D. Contaminants in the water such as microbes, mud, chemicals, and algae do not affect the degree of injury to the lungs.
Correct Answer: C
Rationale: Determining the cause of drowning (C) identifies underlying conditions like seizures for follow-up. Cold water may improve outcomes (A), aspiration reduces surfactant (B), and contaminants worsen lung injury (D).
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A 47-year-old client presents to the emergency department with severe hypotension, muscle weakness, fatigue, and vomiting. Labs reveal a potassium level of 6.1 mEq/L and a sodium level of 128 mEq/L. Which of the following should the nurse anticipate for this client?
- A. administration of IV spironolactone
- B. boluses of Lactated Ringer's to increase blood pressure
- C. administration of IV saline, dextrose, or hydrocortisone
- D. boluses of 0.45% normal saline with 40 mEq/L of potassium
Correct Answer: C
Rationale: Symptoms and labs suggest Addisonian crisis (hypotension, hyperkalemia, hyponatremia). IV saline, dextrose, and hydrocortisone (C) stabilize the client. Spironolactone (A) worsens hyperkalemia, Lactated Ringer's (B) is less specific, and potassium (D) is contraindicated.
The nurse is teaching a newly diagnosed client about Guillain-Barré syndrome (GBS). What information would the nurse provide in her teaching? Select all that apply.
- A. GBS affects females more often than males.
- B. The acute period lasts several days to 2 weeks.
- C. GBS tends to be self-limiting with temporary paralysis.
- D. Common symptoms include muscle weakness and paralysis.
- E. Infections such as Epstein-Barr virus have been associated with GBS.
Correct Answer: C,D,E
Rationale: GBS is self-limiting with temporary paralysis (C), causes muscle weakness/paralysis (D), and is linked to infections like Epstein-Barr (E). It affects males slightly more (A), and the acute phase lasts weeks to months (B).
While in a restaurant the nurse notices a woman clutching her throat. The woman is unable to speak. The nurse asks the woman if she's choking, and she indicates yes. Which response by the nurse should be done first?
- A. establish an airway by tilting the chin back
- B. administer five quick chest compressions
- C. administer two rescue breaths
- D. perform the Heimlich maneuver
Correct Answer: D
Rationale: The Heimlich maneuver (D) is the first action for choking to dislodge the obstruction. Chin tilt (A) and breaths (C) are for unconscious patients, and chest compressions (B) are for cardiac arrest.
The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?
- A. calcium 9.8 mg/dL
- B. sodium 137 mEq/L
- C. chloride 104 mEq/L
- D. potassium 3.1 mEq/L
Correct Answer: D
Rationale: Potassium 3.1 mEq/L (D) indicates hypokalemia, requiring immediate intervention due to risk of arrhythmias. Calcium (A), sodium (B), and chloride (C) are within normal ranges.
The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
- A. cold intolerance
- B. chest pain and anxiety
- C. decreased respirations
- D. hypertension and widening pulse pressure
Correct Answer: B
Rationale: Air embolus during hemodialysis causes chest pain and anxiety (B) due to air blocking pulmonary circulation. Cold intolerance (A), decreased respirations (C), and hypertension (D) are not typical signs.