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A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure?
- A. Ambulate the client.
- B. Clamp the chest tube.
- C. Ask the client to cough and deep breathe.
- D. Ask the client to remain in a side-lying position.
Correct Answer: B
Rationale: After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.
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The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
- A. Assist the client to develop a daily bowel routine to prevent constipation.
- B. Teach the client to manage emotional stressors by using mental imaging.
- C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
- D. Administer dexamethasone orally per the primary health care provider's prescription.
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet?
- A. Spinach
- B. Custard
- C. Scrambled eggs
- D. Mashed potatoes
Correct Answer: A
Rationale: Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.
As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
During a follow-up visit 2 weeks after pneumonectomy, the client reports numbness and tenderness at the surgical site. Which statement should the nurse make to accurately address the client's concerns?
- A. This is not likely to be permanent, but may last for some months.
- B. You are having a severe problem and will probably be rehospitalized
- C. This is probably caused by permanent nerve damage as a result of surgery.
- D. This is often the first sign of a wound infection; I will check your temperature.
Correct Answer: A
Rationale: Clients who undergo pneumonectomy or other surgical procedures may experience numbness, altered sensation, or tenderness in the area that surrounds the incision. These sensations may last for months. It is not considered to be a severe problem and is not indicative of a wound infection.
A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client's report, the nurse should assess which client data?
- A. Rectal temperature
- B. Last serum potassium
- C. Capillary blood glucose
- D. Serum blood urea nitrogen and creatinine
Correct Answer: C
Rationale: Clients receiving TPN are at risk for hyperglycemia related to the increased glucose load of the solution. The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the client's blood glucose level to verify these data. The other options would not provide any information that would correlate with the client's symptoms.