Nokea
A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?
- A. Flail chest
- B. Hemothorax
- C. Pulmonary contusion
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.
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A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?
- A. Respiratory therapy
- B. Hospice care
- C. Occupational therapy
- D. Dietary services
Correct Answer: D
Rationale: The correct answer is D: Dietary services. Referring the client to dietary services is essential for managing nutrition, including monitoring sodium, potassium, and protein intake, which are crucial aspects of managing chronic kidney disease (CKD). Respiratory therapy (choice A) focuses on managing respiratory conditions, which are not directly related to CKD. Hospice care (choice B) is not appropriate for a new diagnosis of CKD as it is designed for end-of-life care. Occupational therapy (choice C) is beneficial for improving activities of daily living but is not the priority referral for a new CKD diagnosis.
A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?
- A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
- B. Administer oxygen to a client who has an oxygen saturation of 91%
- C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
- D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery
Correct Answer: B
Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.
A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not wash my hair prior to the procedure.
- B. I will receive a sedative 1 hour before the procedure.
- C. I should avoid eating prior to the procedure.
- D. I will be exposed to flashes of light during the procedure.
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.
A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. ½ cup of canned baked beans
Correct Answer: C
Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.
While administering a blood transfusion, a nurse suspects that the client is having an adverse reaction. Which of the following actions should the nurse take first?
- A. Maintain IV access
- B. Obtain the client's vital signs
- C. Contact the provider
- D. Stop the transfusion
Correct Answer: D
Rationale: The correct first action for the nurse to take when suspecting an adverse reaction to a blood transfusion is to stop the transfusion immediately. Stopping the transfusion helps prevent further harm to the client. Maintaining IV access and obtaining vital signs are important steps but come after stopping the transfusion in this situation. Contacting the provider can be done after ensuring the client's safety by stopping the transfusion.