Nokea
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
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A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a 2-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?
- A. Complaints of blindness
- B. Decreased respiratory rate and depth
- C. Failure to recognize touch
- D. Inability to identify sweet taste
Correct Answer: C
Rationale: The frontal lobe is involved in sensory processing and cognition, so failure to recognize touch (agnosia) is consistent with frontal lobe injury.
The nurse is caring for an adult who had an appendectomy 6 hours ago. Which intervention would the nurse expect to perform to promote rest and sleep? Select all that apply.
- A. provide a substantial meal of meatloaf, mashed potatoes, corn, and milk
- B. offer Ambien 5 mg as ordered
- C. lower the temperature of the room
- D. change bed linen
Correct Answer: B, C, D
Rationale: Ambien, a cool room, and fresh linens promote rest. A heavy meal may disrupt sleep post-surgery.
A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.
The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
- A. Decreased protein concentration with a normal cell count
- B. Increased protein concentration with a normal cell count
- C. Increased protein concentration with an abnormal cell count
- D. Decreased protein concentration with an abnormal cell count
Correct Answer: B
Rationale: Guillain-Barre syndrome typically shows elevated protein levels in cerebrospinal fluid with a normal cell count, known as albuminocytologic dissociation.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler’s position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm)