Nokea
A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway?
- A. Insert oropharyngeal airway.
- B. Tilt the head and lift the chin.
- C. Place in the recovery position.
- D. Stabilize the skull and push up the jaw.
Correct Answer: D
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.
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A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- C. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
- D. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Correct Answer: B
Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
- A. Sherbet
- B. Steak sauce
- C. Apple juice
- D. Leafy green vegetables
Correct Answer: B
Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. What is the initial nursing action when the client reports itching and a tight sensation in the chest?
- A. Stop the transfusion.
- B. Check the client's temperature.
- C. Call the primary health care provider.
- D. Recheck the unit of blood for compatibility.
Correct Answer: A
Rationale: The symptoms reported by the client indicate that the client is experiencing a transfusion reaction. The first action of the nurse when a transfusion reaction is observed is to discontinue the transfusion. The IV of normal saline with new IV tubing is started and the primary health care provider is notified. The nurse then checks the client's vital signs: temperature, pulse, and respirations and then rechecks the unit of blood as appropriate for infusion into the client.
A client with significant flail chest has arterial blood gases (ABGs) that reveal a PaO2 of 68 and a PaCO2 of 51. Two hours ago the PaO2 was 82 and the PaCO2 was 44. Based on these changes, which item should the nurse assure easy access to in order to help ensure client safety?
- A. Intubation tray
- B. Injectable lidocaine
- C. Chest tube insertion set
- D. Portable chest x-ray machine
Correct Answer: A
Rationale: Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The laboratory results indicate worsening respiratory acidosis. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end-expiratory pressure (PEEP); therefore, an intubation tray is necessary. None of the other options have a direct purpose with the client's current respiratory status.