Nokea
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.
You may also like to solve these questions
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my medication with food to increase absorption.
- B. If my heart starts racing
- C. my provider might need to adjust my dosage.
- D. I will stop taking this medication once I feel better.
- E. I should take this medication at night before bed.
Correct Answer: B
Rationale: The correct answer is B because it indicates the client understands the potential side effect of levothyroxine, which is palpitations or a racing heart. This shows awareness of the need to monitor and report adverse effects to the healthcare provider promptly. Taking the medication with food (A) actually decreases its absorption. Dosage adjustments (C) are common in thyroid medication but don't necessarily demonstrate immediate understanding. Stopping the medication once feeling better (D) is incorrect as levothyroxine is usually a lifelong treatment. Taking medication at night (E) is not crucial for levothyroxine as long as it is taken consistently.
A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: Correct Answer: A: Maintain low intermittent suction.
Rationale: Maintaining low intermittent suction helps to decompress the bowel, reducing the risk of further obstruction. Suction also helps to remove excess fluid and gas from the digestive system, providing relief to the client. It is essential to prevent excessive suction, as it can cause damage to the bowel and worsen the obstruction.
Summary of other choices:
B: Clamping the NG tube every 2 hours is not recommended as it can lead to a buildup of fluid and gas in the bowel, potentially worsening the obstruction.
C: Removing the NG tube immediately is contraindicated as it is necessary for decompression and monitoring of bowel function.
D: Encouraging high-fiber foods is inappropriate in the case of a small bowel obstruction as it can further obstruct the bowel.
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
- A. Skin changes
- B. Hypertension
- C. Diarrhea
- D. Increased white blood cell count
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (B), diarrhea (C), and increased white blood cell count (D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.