Nokea
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
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The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea
The nurse is caring for a client with a history of type 2 diabetes who is receiving glipizide (Glucotrol) 5 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and shakiness.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a serious glipizide side effect. Options A, C, and D are less urgent.
A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important?
- A. Ensure that the client has nothing to eat or drink.
- B. Obtain a 'clean-catch' urine specimen for analysis.
- C. Provide warm packs to relieve discomfort.
- D. Measure and strain the client's urine.
Correct Answer: D
Rationale: will document passage of stone and allow composition to be analyzed
Which of the following is the best plan of care that would meet the needs of this client INITIALLY?
- A. Point out to the client the secondary gain that results from her behavior.
- B. Demonstrate to the client the irrational nature of these fears.
- C. Encourage the client to rely on significant others for support.
- D. Allow the client to avoid the situations that are anxiety provoking.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) secondary gain (attention and assistance received) is not the motivation of a phobic patient, remain nonjudgmental (2) ineffective in relieving behavior, may increase anxiety and feelings of guilt (3) should encourage patient to remain independent (4) correct-phobia is fixed channel for discharge of tension from unconscious conflict
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.