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A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What should the nurse monitor to determine the presence of carbon monoxide poisoning?
- A. Pulse oximetry
- B. Urine myoglobin
- C. Sputum carbon levels
- D. Serum carboxyhemoglobin levels
Correct Answer: D
Rationale: Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen under pressure (hyperbaric oxygen therapy). Options 1, 2, and 3 would not identify carbon monoxide poisoning.
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A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding should the nurse most likely expect to note?
- A. Increased urine output
- B. Increased blood pressure
- C. Decreased fetal heart rate
- D. Decreased brachial reflexes
Correct Answer: B
Rationale: The major manifestation of gestational hypertension is increased blood pressure. As the disease progresses, it is possible that increased brachial reflexes, decreased fetal heart rate and variability, and decreased urine output will occur, particularly during labor.
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
- A. Stop movement of the affected part.
- B. Massage the affected part vigorously.
- C. Notify the primary health care provider immediately.
- D. Force movement of the joint supporting the muscle.
- E. Ask the client to stand and walk rapidly around the room.
- F. Place continuous gentle pressure on the muscle group until it relaxes.
Correct Answer: A,F
Rationale: ROM exercises should put each joint through as full a range of motion as possible without causing discomfort. An unexpected outcome is the development of spastic muscle contraction during ROM exercises. If this occurs, the nurse should stop movement of the affected part and place continuous gentle pressure on the muscle group until it relaxes. Once the contraction subsides, the exercises are resumed using slower, steady movement. Massaging the affected part vigorously may worsen the contraction. There is no need to notify the primary health care provider unless intervention is ineffective. The nurse should never force movement of a joint. Asking the client to stand and walk rapidly around the room is an inappropriate measure.
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?
- A. Weight gain
- B. Night sweats
- C. Severe lymph node pain
- D. Headache with minor visual changes
Correct Answer: B
Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse should assess for which expected but adverse effect of PEEP?
- A. Decreased peak pressure on the ventilator
- B. Increased rectal temperature from 98°F to 100°F
- C. Decreased heart rate from 78 to 64 beats per minute
- D. Systolic blood pressure decrease from 122 to 98 mm Hg
Correct Answer: D
Rationale: PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.