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A nurse is caring for a patient who is post-operative following a lung resection. The nurse should monitor for which of the following signs of complications?
- A. Increased respiratory rate and dyspnea.
- B. Constipation and abdominal distension.
- C. Nausea and vomiting.
- D. Muscle weakness and fatigue.
Correct Answer: A
Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early.
Incorrect choices:
B: Constipation and abdominal distension are not directly related to post-operative lung resection complications.
C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection.
D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.
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A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
- A. Pain and swelling in the leg.
- B. Redness and warmth around the affected area.
- C. Shortness of breath and chest pain.
- D. Pale skin and decreased pulse in the affected leg.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function.
A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism.
B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism.
D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
What should be the nurse's first action when caring for a client with a traumatic amputation?
- A. Apply pressure and elevate the limb
- B. Stop the bleeding and control shock
- C. Place the client in a Trendelenburg position
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications.
Summary of why other choices are incorrect:
B: Stopping bleeding and controlling shock can be important but not the first action.
C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding.
D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.
What is the most appropriate action when a parent crosses their arms and legs during an interview?
- A. Just changing positions
- B. More comfortable in this position
- C. Tired and needs a break
- D. Uncomfortable talking about his son's treatment
Correct Answer: D
Rationale: The correct answer is D because crossing arms and legs can indicate defensiveness or discomfort, which may suggest the parent is uneasy discussing their son's treatment. This nonverbal cue could signal a need for empathy and sensitivity in communication. Choice A is incorrect as it overlooks the significance of body language. Choice B assumes comfort without considering the context. Choice C assumes tiredness without considering other possibilities. Understanding body language cues can help in building rapport and addressing concerns effectively.