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A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.
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A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
- A. Avoid foods high in fat.
- B. Avoid foods high in carbohydrates.
- C. Eat a high-protein, low-fat diet.
- D. Increase intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in fat. Biliary colic is caused by gallstones, and high-fat foods can trigger gallbladder contractions leading to pain. Therefore, advising the client to avoid foods high in fat can help prevent biliary colic episodes. Choice B is incorrect as carbohydrates do not directly affect biliary colic. Choice C is incorrect because while a high-protein, low-fat diet may be beneficial for some conditions, it is not specifically recommended for biliary colic. Choice D is incorrect as increasing intake of high-fat foods can worsen symptoms.
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
- A. It is caused by the lack of production of aldosterone by the adrenal gland.
- B. It is caused by a viral infection.
- C. It is caused by the overproduction of cortisol.
- D. It is caused by an autoimmune disorder.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Addison's disease is characterized by adrenal insufficiency.
2. Aldosterone is a hormone produced by the adrenal gland that helps regulate blood pressure and electrolyte balance.
3. Lack of aldosterone production in Addison's disease leads to electrolyte imbalances and low blood pressure.
4. Therefore, the correct answer is A as the lack of aldosterone production by the adrenal gland is the primary cause of Addison's disease.
Summary of other choices:
B. Addison's disease is not caused by a viral infection, so this choice is incorrect.
C. Addison's disease is not caused by the overproduction of cortisol, as it is associated with cortisol deficiency.
D. The most common cause of Addison's disease is an autoimmune disorder where the body attacks the adrenal glands, leading to their dysfunction.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
- A. Excessive thrombosis and bleeding
- B. Clotting of the mucous membranes
- C. Increase in platelet count
- D. Excessive red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.