Nokea
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.
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A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply.
- A. Restrict the client's movements.
- B. Turn the supine client to the side.
- C. Open the unconscious client's airway.
- D. Gently guide the standing client to the floor.
- E. Place a padded tongue blade into the client's mouth.
- F. Loosen any restrictive clothing that the client is wearing.
Correct Answer: B,C,D,F
Rationale: Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.
The nurse has admitted a client diagnosed with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?
- A. Seizures
- B. Hallucinations
- C. Placenta previa
- D. Altered respiratory status
Correct Answer: A
Rationale: Gestational hypertension can lead to preeclampsia and eclampsia; therefore, a major complication of gestational hypertension is seizures. Hallucinations, placenta previa, and altered respiratory status are not directly associated with gestational hypertension.
A client states, 'I'm sure I have restless leg syndrome.' The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
- A. A heavy feeling in the legs
- B. Burning sensations in the limbs
- C. Symptom relief when lying down
- D. Decreased ability to move the legs
- E. Symptoms that are worse in the morning
- F. Feeling the need to move the limbs repeatedly
Correct Answer: A,C,D,E
Rationale: Restless leg syndrome is characterized by leg paresthesia associated with an irresistible urge to move. The client complains of intense burning or 'crawling-type' sensations in the limbs and subsequently feels the need to move the limbs repeatedly to relieve the symptoms. The symptoms are worse in the evening and night when the client is still.
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 clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?
- A. Radiation is the treatment of choice.
- B. The most significant symptoms are headache and vomiting.
- C. Head shaving is not required before removal of the brain tumor.
- D. Surgery is not normally performed because of the increased risk of functional deficits.
Correct Answer: B
Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children.