Nokea
A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
- A. Diminished breath sounds on the right
- B. Left-sided tracheal deviation
- C. Right-sided tracheal deviation
- D. Presence of bilateral ronchi
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
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An adult has been diagnosed with gout. Which comment by the client indicates to the nurse that the client understands management of the condition?
- A. It has been hard to give up chicken and liver.'
- B. I have shrimp two or three times a week.'
- C. My favorite snack is nuts.'
- D. I have oatmeal every day for breakfast.'
Correct Answer: D
Rationale: Oatmeal is low-purine, suitable for gout management, unlike chicken, liver, or shrimp, which are high-purine and increase uric acid. Nuts are moderate and less ideal.
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
- A. Blood transfusion
- B. Hemodialysis
- C. Renal biopsy
- D. Brain scan
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any skin rash.
- C. Stop the medication if gout attacks cease.
- D. Avoid drinking plenty of water.
Correct Answer: B
Rationale: A skin rash may indicate a hypersensitivity reaction to allopurinol, requiring immediate reporting. Options A, C, and D are incorrect.
The nurse is caring for a client with a history of myocardial infarction.
- A. Which instruction is most important for a client post-myocardial infarction?
- B. Avoid heavy lifting for 6 weeks.
- C. Take nitroglycerin only when chest pain occurs.
- D. Resume normal activity immediately.
- E. Monitor blood pressure weekly.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.