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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The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis?
- A. An evening sweat potassium concentration greater than 60 mEq/L
- B. A sweat chloride concentration that is consistently greater 60 mEq/L
- C. An early morning sweat chloride concentration of less than 40 mEq/L
- D. A sweat potassium concentration that is consistently less than 40 mEq/L
Correct Answer: B
Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to the sweat test.
A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse should plan to keep which item available in the client's room to assist in this process?
- A. A urine strainer
- B. A calorie count sheet
- C. A vital signs graphic sheet
- D. An intake and output record
Correct Answer: A
Rationale: The urine is strained until the stone is passed, obtained, and analyzed. Straining the urine will catch small stones that should be sent to the laboratory for analysis. Once the type of stone is determined, an individualized plan of care for prevention and treatment is developed. Options 2, 3, and 4 are unrelated to the question.
The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
The nurse plans care for a client requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
- A. Hyponatremia
- B. Bounding pulse rate
- C. Chronic kidney disease
- D. Isolated syncope episodes
- E. Rapid, weak, and thready pulse
- F. Abnormal serum and urine osmolality levels
Correct Answer: A,E,F
Rationale: Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.
When a client with a chest injury is suspected of experiencing a pleural effusion, which typical manifestations of this respiratory problem should the nurse assess for? Select all that apply.
- A. Dry cough
- B. Moist cough
- C. Dyspnea at rest
- D. Productive cough
- E. Dyspnea on exertion
- F. Nonproductive cough
Correct Answer: A,E,F
Rationale: A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.