Nokea
A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?
- A. Ensure that the client is appropriately dressed.
- B. Administer an opioid analgesic 30 to 60 minutes before therapy.
- C. Schedule the therapy at a time when the client generally takes a nap.
- D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B
Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.
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The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply.
- A. Hypertension
- B. Flat neck veins
- C. Increased cyanosis
- D. Tracheal deviation to the right
- E. Diminished breath sounds on the left
- F. Observable asymmetry of the thorax
Correct Answer: C,D,E,F
Rationale: A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise.