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A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?
- A. Bubbling of the water in the water seal chamber with exhalation
- B. Crepitus in the area above and surrounding the insertion site
- C. Movement of the trachea toward the unaffected side
- D. Eyelets are not visible
Correct Answer: B
Rationale: Crepitus indicates subcutaneous emphysema, which requires immediate attention as it suggests air leaking into tissues.
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A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.
The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- A. I was an intravenous drug abuser in the past and shared needles.
- B. I ate shellfish about 2 weeks ago at a local restaurant.
- C. I had a blood transfusion 30 years ago after major abdominal surgery.
- D. I have had unprotected sex with multiple partners.
Correct Answer: B
Rationale: Hepatitis A is typically transmitted through contaminated food/water - shellfish is a known source.
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.
A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
- A. MI only occurs with exertion.
- B. Stable angina can occur for longer than 30 minutes.
- C. Stable angina can be relieved with rest and nitroglycerin.
- D. The pain of an MI lasts less than 15 minutes.
Correct Answer: C
Rationale: Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, while MI pain is more prolonged and severe and not relieved by these measures.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.