A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?
- A. A client who has a BMI of 30
- B. A female client who is postmenopausal
- C. A client who has a fractured femur
- D. A client who has chronic atrial fibrillation
Correct Answer: B
Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.
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When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?
- A. Air should be instilled into the monitoring system after the procedure.
- B. The client should be positioned on the left side after the procedure.
- C. The transducer should be level with the second intercostal space after the line is placed.
- D. A chest x-ray is needed to verify placement after the procedure.
Correct Answer: D
Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.
When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?
- A. Administer antibiotics
- B. Provide supplemental oxygen
- C. Administer antiviral medications
- D. Administer bronchodilators
Correct Answer: A
Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.
A client has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
- A. Your urine can turn a dark orange.
- B. Watch for a change in the sclera of your eyes.
- C. Watch for any changes in vision.
- D. Take vitamin B6 daily.
Correct Answer: C
Rationale: Ethambutol is associated with potential vision changes, including optic neuritis. Patients should be instructed to report any visual disturbances immediately to prevent permanent vision loss. Monitoring for changes in vision is crucial to detect any adverse effects early on and prevent serious complications.
A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?
- A. Tachypnea
- B. Deviation of the trachea
- C. Bradycardia
- D. Pleuritic pain
Correct Answer: C
Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.
A healthcare professional is reviewing the health records of five clients. Which of the following clients is not at risk for developing acute respiratory distress syndrome?
- A. A client who experienced a near-drowning incident
- B. A client following coronary artery bypass graft surgery
- C. A client who has a hemoglobin of 15.1 g/dL
- D. A client who has dysphagia
Correct Answer: C
Rationale: Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be triggered by various factors such as near-drowning incidents, surgeries like coronary artery bypass graft, and underlying conditions like dysphagia. Hemoglobin levels do not directly influence the risk of developing ARDS. A hemoglobin level of 15.1 g/dL falls within the normal range and does not predispose an individual to ARDS.