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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.
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A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
- A. Dysmenorrhea that is unresponsive to NSAIDs
- B. Heavy menstrual bleeding
- C. Positive family history of fibroids
- D. Pelvic pain after intercourse
Correct Answer: A
Rationale: The correct answer is A: Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis is characterized by severe menstrual pain that is not relieved by NSAIDs. This is due to the abnormal growth of endometrial tissue outside the uterus. Heavy menstrual bleeding (B) is a common symptom but not specific to endometriosis. Positive family history of fibroids (C) is unrelated to endometriosis. Pelvic pain after intercourse (D) can be a symptom of endometriosis but is not as specific as unresponsive dysmenorrhea.
A nurse explains to a client why two chest tubes are in place after a lobectomy. What is the lower chest tube for?
- A. Draining air from the pleural space
- B. Draining blood and fluid from the pleural space
- C. Providing oxygen directly to the lungs
- D. Preventing lung collapse
Correct Answer: B
Rationale: The lower chest tube after a lobectomy is to drain blood and fluid from the pleural space. This is crucial to prevent complications such as fluid accumulation, which can lead to infection or impaired lung expansion. The other choices are incorrect because: A) Draining air is usually done by the upper chest tube, C) Providing oxygen does not require a chest tube, and D) Preventing lung collapse is more related to the function of the upper chest tube in maintaining negative pressure in the pleural space.
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
- A. I may eat 10 ounces of lean protein each day
- B. I will limit my sodium intake.
- C. I will increase my intake of fruits and vegetables.
- D. I will avoid fried foods and processed meats.
Correct Answer: A
Rationale: The correct answer is A: "I may eat 10 ounces of lean protein each day." This statement indicates a need for further teaching because consuming 10 ounces of lean protein daily may lead to excessive protein intake, which can strain the kidneys and potentially worsen hypertension. Clients with hypertension should limit protein intake and focus on lean sources in moderation. Choices B, C, and D are correct as they align with a heart-healthy diet by limiting sodium intake, increasing fruits and vegetables, and avoiding fried foods and processed meats, respectively.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
- A. Fine crackles in the lungs
- B. Increased anteroposterior diameter of the chest
- C. Increased tactile fremitus
- D. Fever and chills
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD with emphysema, there is air trapping leading to hyperinflation of the lungs, causing the chest to expand more in the front-to-back direction (increased anteroposterior diameter). This is known as barrel chest.
A: Fine crackles are not typically associated with COPD/emphysema, they are more common in conditions like heart failure or pneumonia.
C: Increased tactile fremitus is not typically seen in COPD/emphysema, it may be present in conditions like pneumonia.
D: Fever and chills are not typical findings in COPD/emphysema unless there is an infection present.