Nokea
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
- A. Inspect the pin sites at least every 8 hr.
- B. Apply direct pressure to pin sites.
- C. Remove traction weights for comfort.
- D. Encourage vigorous movement of the affected limb.
Correct Answer: A
Rationale: Correct Answer: A. Inspect the pin sites at least every 8 hr.
Rationale:
1. Inspecting pin sites regularly is crucial to monitor for signs of infection or other complications.
2. Postoperative clients with skeletal traction are at high risk for pin site infections.
3. Regular inspection allows early detection and intervention to prevent complications.
4. Waiting longer than every 8 hours may lead to delayed identification of issues.
Summary:
B. Applying direct pressure is contraindicated as it can cause harm.
C. Removing traction weights without medical order can lead to complications.
D. Encouraging vigorous movement is inappropriate and can cause harm.
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A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
- A. Avoid high-fat cuts of meat.
- B. Increase your intake of fried foods.
- C. Consume dairy products at every meal.
- D. Eat large meals to avoid frequent digestion.
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation. Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
- A. Mild wheezing
- B. Use of accessory muscles
- C. Decreased respiratory rate
- D. Productive cough
Correct Answer: B
Rationale: The correct answer is B: Use of accessory muscles. In status asthmaticus, a severe and life-threatening asthma exacerbation, the client's airways are severely constricted, leading to inadequate air exchange. The use of accessory muscles (such as intercostal and supraclavicular muscles) indicates significant respiratory distress as the body tries to compensate for the difficulty in breathing. Mild wheezing (choice A) may be present in asthma but does not necessarily indicate status asthmaticus. Decreased respiratory rate (choice C) is not consistent with the increased respiratory effort seen in status asthmaticus. Productive cough (choice D) is more indicative of conditions such as bronchitis or pneumonia, not necessarily status asthmaticus.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.)
- A. Excessive somnolence
- B. Epistaxis
- C. Pink frothy sputum
- D. Tachypnea
- E. Urinary frequency
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
- A. Sinus bradycardia
- B. Atrial fibrillation
- C. Ventricular tachycardia
- D. First-degree heart block
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
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.