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A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect? What finding should the nurse expect in left-sided heart failure?
- A. Frothy sputum
- B. Dependent edema
- C. Nocturnal polyuria
- D. Jugular distention
Correct Answer: A
Rationale: The correct answer is A: Frothy sputum. In left-sided heart failure, the failing left ventricle results in blood backing up into the lungs causing pulmonary congestion. This leads to the production of frothy, pink-tinged sputum due to blood-tinged fluid leaking into the alveoli. Dependent edema (choice B) is more indicative of right-sided heart failure. Nocturnal polyuria (choice C) is not a typical finding in left-sided heart failure. Jugular distention (choice D) is more commonly seen in right-sided heart failure due to increased venous pressure.
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A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain. The nurse notes that the patient's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? What condition is indicated by paradoxical chest movement?
- A. Flail chest
- B. Hemothorax
- C. Atelectasis
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest is characterized by a segment of the rib cage that moves independently due to multiple rib fractures. The paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration, is a classic sign of flail chest. This occurs due to the loss of stability in the rib cage, leading to ineffective breathing mechanics.
Incorrect answers:
B: Hemothorax - This is the accumulation of blood in the pleural cavity, which would not cause paradoxical chest movement.
C: Atelectasis - Atelectasis is the collapse of lung tissue, which would not result in paradoxical chest movement.
D: Pneumothorax - Pneumothorax is the presence of air in the pleural space, which typically causes chest pain and shortness of breath but does not result in paradoxical chest movement.
A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.
A nurse is attending to a patient with a wound infection. What should the nurse do when collecting a wound-drainage specimen for culture? What should the nurse do for wound culture collection?
- A. Swab an area of skin away from the wound to identify the usual flora.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
- D. Include intact skin at the wound edges in the culture.
Correct Answer: C
Rationale: The correct answer is C: Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. This step is essential to ensure that the sample collected is not contaminated with external bacteria, which could lead to inaccurate results. By cleansing the wound with a sterile solution like saline, the nurse can remove debris and bacteria from the wound surface, increasing the likelihood of obtaining an accurate culture. Swabbing an area away from the wound (choice A) would not provide an accurate representation of the bacteria present in the wound. Irrigating the wound with an antiseptic (choice B) could potentially interfere with the culture results by killing the bacteria being tested for. Including intact skin at the wound edges in the culture (choice D) is unnecessary and could introduce contaminants. Overall, choice C is the most appropriate step to ensure a reliable wound culture.
A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse's priority? Which observation is the priority for epidural analgesia?
- A. The patient's blood pressure is 80/56 mm Hg.
- B. The patient reports lower extremity weakness.
- C. The patient's temperature is 38.2°C (100.8 F).
- D. The patient reports severe itching.
Correct Answer: A
Rationale: The correct answer is A: The patient's blood pressure is 80/56 mm Hg. This is the priority observation because hypotension is a common side effect of epidural analgesia, which can lead to decreased perfusion and compromise fetal well-being. Lower extremity weakness (B) is expected due to the effect of the epidural. Temperature elevation (C) can be due to various factors unrelated to the epidural. Severe itching (D) can be a side effect but is not life-threatening like hypotension.
A nurse is conducting discharge teaching for a patient who has seizures and a new prescription for phenytoin. Which statements by the patient indicate a need for further teaching? Which statement indicates a need for phenytoin teaching?
- A. I know that I cannot switch brands of this medication.
- B. I have made an appointment to see my dentist next week.
- C. I will notify my doctor before taking any other medications.
- D. I'll be glad when I can stop taking this medicine.
Correct Answer: D
Rationale: The correct answer is D: "I'll be glad when I can stop taking this medicine." This statement indicates a need for further teaching because phenytoin is typically a lifelong medication for managing seizures. Stopping it abruptly can lead to serious consequences such as increased risk of seizures. Therefore, the patient should be educated on the importance of adhering to the prescribed regimen.
Choice A is correct because it emphasizes the importance of not switching brands of phenytoin, as different formulations may have varying levels of the active ingredient. Choice B is important for overall health but not directly related to phenytoin teaching. Choice C is also crucial as phenytoin can interact with other medications, so notifying the doctor is necessary.
In summary, choice D is incorrect because discontinuing phenytoin without medical supervision can be harmful. Choices A, B, and C are correct as they address important aspects of managing phenytoin therapy.