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A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?
- A. A WBC of 14,000 cu.mm
- B. Auscultation of abdominal bruit
- C. Complaints of lower back pain
- D. A platelet count of 175,000 cu.mm
Correct Answer: A
Rationale: A WBC of 14,000 cu.mm indicates possible infection or inflammation, which is concerning pre-surgery and should be reported. Abdominal bruit and lower back pain are expected with an abdominal aortic aneurysm, and a platelet count of 175,000 is normal.
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A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
- A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake
- B. Purse the lips and take quick, short breaths approximately 18-20 times/min
- C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series
- D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
Correct Answer: A
Rationale: This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. An asthma attack
- C. Pneumonia
- D. Pulmonary embolus
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?
- A. Normal vital signs
- B. Fever
- C. Tachycardia
- D. Hypotension
Correct Answer: A
Rationale: Postpartum depression is a psychological condition and typically does not cause vital sign changes. Fever tachycardia or hypotension suggest physical conditions like infection or hemorrhage.
A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?
- A. The nurse lowers the temperature of the room.
- B. The nurse places an airway at the bedside.
- C. The nurse inserts an indwelling catheter and obtains an hourly intake and output.
- D. The nurse darkens the room to reduce environmental stimuli.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.