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A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
- A. Pneumonia
- B. Pulmonary contusions
- C. Pulmonary edema
- D. Tension pneumothorax
Correct Answer: B
Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.
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The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Hypothermia
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (B), nausea (C), and hyperactivity (D) are not associated with clopidogrel.
A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:
- A. Avoid salty foods
- B. Increase fluid intake
- C. Take the medication with meals
- D. Monitor for weight loss
Correct Answer: B
Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid 'vena caval syndrome,' a condition which:
- A. Occurs when blood pressure increases sharply with changes in position
- B. Results when blood flow from the extremities is blocked or slowed
- C. Is seen mainly in first pregnancies
- D. May require medication if positioning does not help
Correct Answer: B
Rationale: Vena caval syndrome occurs when the gravid uterus compresses the inferior vena cava, slowing blood return from the extremities.
The client with a history of seizures is prescribed phenytoin (Dilantin). Which instruction should the nurse include in the teaching plan?
- A. Take the medication with milk to prevent stomach upset.'
- B. Avoid alcohol while taking this medication.'
- C. You can stop the medication if you have no seizures for a month.'
- D. Take an extra dose if you feel a seizure coming on.'
Correct Answer: B
Rationale: Alcohol can interact with phenytoin, increasing toxicity or reducing efficacy, so it should be avoided. Milk does not prevent GI upset, stopping medication requires physician guidance, and extra doses are dangerous.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.