Nokea
A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client?
- A. Cyanosis and slow respirations
- B. Slight bradypnea with shallow breaths
- C. Pallor and paradoxical chest movement
- D. Severe dyspnea and paradoxical chest movement
Correct Answer: D
Rationale: The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature.
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A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never acted this way before. The nurse's best response is:
- A. I understand your concern. Let's discuss what specific changes you've noticed.'
- B. Delirium is common in older adults and usually resolves quickly.'
- C. We'll run some tests to find out what's causing this behavior.'
- D. Don't worry, we'll take good care of her.'
Correct Answer: A
Rationale: Discussing specific changes encourages the daughter to provide details, aiding in identifying the delirium's cause and tailoring care.
A client with a history of chronic kidney disease is prescribed calcitriol (Rocaltrol). The nurse should instruct the client to:
- A. Monitor for signs of hypercalcemia.
- B. Take the medication on an empty stomach.
- C. Avoid phosphorus-rich foods.
- D. Stop the medication if nausea occurs.
Correct Answer: A
Rationale: Calcitriol can cause hypercalcemia, requiring monitoring for symptoms like confusion.
Which of the following should be the nurse's priority assessment after an epidural anesthetic has been administered to a client in labor?
- A. Level of consciousness.
- B. Blood pressure.
- C. Cognitive function.
- D. Contraction pattern.
Correct Answer: B
Rationale: Epidurals can cause hypotension due to vasodilation, making blood pressure the priority assessment.
A client with a fracture is placed in skeletal traction. What is the nurse's priority assessment?
- A. Skin integrity at pin sites.
- B. Range of motion in the affected limb.
- C. Pain level during movement.
- D. Muscle strength in the unaffected limb.
Correct Answer: A
Rationale: Monitoring skin integrity at pin sites is critical to detect infection or tissue breakdown in skeletal traction.
A client with a history of Addison's disease is prescribed hydrocortisone. Which instruction should the nurse include?
- A. Take it on an empty stomach
- B. Double the dose during stress
- C. Stop it if weight gain occurs
- D. Take it at bedtime only
Correct Answer: B
Rationale: Doubling hydrocortisone during stress (e.g., illness) prevents adrenal crisis in Addison's disease, mimicking the body's natural cortisol response.