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A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.
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A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
- A. Observing for symmetrical chest rise and fall
- B. Auscultating bilateral breath sounds
- C. Using an end-tidal COâ‚‚ detector
- D. Checking for condensation in the ET tube
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
- A. Bronchoconstriction
- B. Refractory hypoxemia
- C. Pulmonary hypertension
- D. Pleural effusion
Correct Answer: B
Rationale: Correct Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
- A. Avoid dairy products.
- B. Use disposable utensils for meals.
- C. Sleep next to family members.
- D. Increase iodine-rich foods in your diet.
Correct Answer: B
Rationale: The correct answer is B: Use disposable utensils for meals. This is important to prevent contamination of utensils by the radioactive iodine, which can be harmful to others. A - Avoiding dairy products is irrelevant for radioactive iodine therapy. C - Sleeping next to family members can expose them to radiation. D - Increasing iodine-rich foods can interfere with the therapy. Thus, B is the most appropriate instruction to include in the teaching.
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.