Nokea
A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma?
- A. Diminished bilateral breath sounds.
- B. A skilled heart sounds.
- C. Respiratory distress.
- D. Tracheal deviation.
Correct Answer: C
Rationale: Respiratory distress is an early sign of tension pneumothorax due to increasing intrathoracic pressure. Diminished breath sounds and tracheal deviation are later signs. 'Skilled heart sounds' is likely a typo and unclear.
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The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
- A. 1 to 2 minutes.
- B. 4 to 6 minutes.
- C. 8 to 10 minutes.
- D. 12 to 15 minutes.
Correct Answer: B
Rationale: Brain damage begins after 4 to 6 minutes without oxygenation, making this the critical window for initiating CPR to prevent permanent damage.
Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:
- A. Decreased cellular demand for oxygen.
- B. Reduced episodes of coughing.
- C. Diminished pain when breathing deeply.
- D. Ability to expectorate secretions more easily.
Correct Answer: A
Rationale: Bed rest reduces oxygen demand by decreasing metabolic rate, aiding recovery in pneumonia. Reduced coughing, diminished pain, and easier expectoration are secondary benefits but not the primary measure of bed rest effectiveness.
A client with osteoarthritis asks about dietary changes to manage symptoms. Which recommendation is most appropriate?
- A. Increase intake of red meat.
- B. Consume foods rich in omega-3 fatty acids.
- C. Avoid all dairy products.
- D. Limit fruit consumption.
Correct Answer: B
Rationale: Omega-3 fatty acids have anti-inflammatory properties, helping manage osteoarthritis symptoms.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
The family members caring for a 72-year-old client who is near death from colon cancer are concerned about dehydration. What should the nurse tell them about dehydration at end of life?
- A. The physician will make the decision regarding hydration therapy.
- B. Dehydration may prolong the dying process.
- C. Hydration is used only in extreme situations of dehydration.
- D. Dehydration is expected during the dying process.
Correct Answer: D
Rationale: Dehydration is a natural part of the dying process and is often not treated aggressively in hospice care, as it may not cause discomfort and can reduce symptoms like edema.