Nokea
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
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A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
The nurse includes the problem of 'Risk for infection' in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?
- A. Hematocrit of 33% (0.33 volume fraction).
- B. White blood cell count of 1,500/mm3 (1.5 x 10°)
- C. Hemoglobin of 10 g/dl (6.21 mmol/L)
- D. Red blood cell count of 3.5 x 10l(3.5 x 10°).
Correct Answer: B
Rationale: A low white blood cell count (1,500/mm³) indicates leukopenia, increasing infection risk, unlike other values.
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?
- A. Schedule a portable chest x-ray per PRN protocol.
- B. Maintain the current IV antibiotic schedule.
- C. Obtain a specimen of the drainage for culture.
- D. Milk' the tube to remove any clots.
Correct Answer: C
Rationale: A culture of the changed drainage assesses for infection or other causes, prioritizing over imaging, antibiotics, or tube manipulation.
Nurses votes
Skin assessment reveals a stage 2 pressure injury on the right trochanter. Measures 0.79" x 1.57" x 0.39 (2 cm X 4 cm X 1 cm). Minimal drainage noted. Painful to touch. The Braden Scale was utilized during the skin assessment. The score is two for sensory, three for moisture, two for activity, two for mobility, two for nutrition and one for friction and shear.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
A. Begin enteral feedings
B. Insert Indwelling urinary catheter
C. Ambulate every four
D. Apply pressure reduction mattress to bed
E. Request service of wound care nurse
- B. Potential Conditions
Choices
A. Immobility
B. Dehydration
C. Malnutrition
D. Poor healing of stage 2 pressure injury
- C. Parameters to monitor
Choices
A. Sterile dressing changes
B. Adherence to repositioning schedule hours
C. Temperature
D. Laboratory studies for malnutrition status
E. Progression of wound
Correct Answer: D
Rationale: Poor healing of a pressure injury requires a pressure reduction mattress and wound care nurse consultation, monitoring wound progression and repositioning adherence.