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A patient, age 46, is admitted for observation following an auto accident. He hit the steering wheel and has a chest contusion. Which of the following creates a pericardial friction rub?
- A. Inflamed cardiac tricuspid and mitral valves
- B. Decreased cardiac output c.Increased pulmonary pressures
- C. Rubbing of pericardial and epicardial layers
Correct Answer: C
Rationale: A pericardial friction rub is a harsh grating sound caused by the rubbing of the pericardial and epicardial layers of the heart. This rubbing sound can be heard with a stethoscope and is typically indicative of pericarditis, inflammation of the pericardium (the sac surrounding the heart). In the case of the patient with a chest contusion following an auto accident, the trauma could have led to pericardial inflammation and subsequent pericardial friction rub. The other choices do not directly result in the creation of a pericardial friction rub.
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Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
- A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
- B. Encourage fluids to flush dye from the patient's system.
- C. Monitor the patient for return to consciousness.
- D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D
Rationale: After a bronchoscopy procedure, it is essential to check for the presence of a gag reflex before allowing the patient to drink. This is crucial to prevent aspiration, as the gag reflex helps protect the airway by triggering swallowing and preventing foreign material from entering the lungs. Allowing the patient to drink without assessing the gag reflex could lead to serious complications such as aspiration pneumonia. Therefore, checking for the gag reflex is an appropriate nursing action to ensure the safety and well-being of the patient after a bronchoscopy.
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
- A. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
- B. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
- C. Flat, brown mole less than 1 cm in diameter
- D. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.
The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.