Nokea
A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?
- A. The patient will be admitted to the medicine unit for observation and medication.
- B. The patient will be admitted to the day surgery unit for sclerotherapy.
- C. The patient will be admitted to the surgical unit and resection will be scheduled.
- D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Correct Answer: C
Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.
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A healthcare provider calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the healthcare provider most likely observed?
- A. The patient is somnolent with decreased response to stimuli.
- B. The patient suddenly complains of chest pain and shortness of breath.
- C. The patient has developed a wet cough and the healthcare provider hears crackles on auscultation of the lungs.
- D. The patient has a fever, chills, and loss of appetite.
Correct Answer: B
Rationale: The correct answer is 'The patient suddenly complains of chest pain and shortness of breath.' Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism"?because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism"?must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. Choices A, C, and D describe symptoms that are not typically associated with a pulmonary embolism, making them incorrect.
The nurse is caring for a 27-year-old female client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb compression therapy
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. This leads to inadequate oxygen and nutrient supply to the cells in the lower extremities, resulting in cell death or necrosis. Venous stasis ulcers, characterized by shallow brown wounds with irregular margins, typically develop on the lower leg or ankle. The primary goal in managing clients with venous stasis ulcers is to promote healing. Proper nutrition plays a crucial role in wound healing. Nutritional deficiencies are common causes of venous ulcers, and a diet rich in protein, iron, zinc, and vitamins C and A is recommended to enhance wound healing. Applying dressings with sterile technique, initiating limb compression therapy, and beginning proteolytic debridement are important interventions in wound care but may not directly address the underlying issue of poor nutrition that is essential for healing venous stasis ulcers.
A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
- A. Slow pulse rate
- B. Weight gain
- C. Decreased systolic pressure
- D. Irregular WBC lab values
Correct Answer: B
Rationale: Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart is unable to circulate blood normally, the kidneys receive less blood, leading to reduced fluid filtration into the urine. The excess fluid accumulates in various body parts such as the lungs, liver, eyes, and sometimes in the legs. Slow pulse rate (Choice A) is less likely as infants with heart failure typically present with tachycardia due to the body compensating for decreased cardiac output. Decreased systolic pressure (Choice C) is also less likely as heart failure typically leads to increased blood pressure as the body tries to maintain adequate perfusion. Irregular white blood cell (WBC) values (Choice D) are not directly associated with congenital heart defects unless there is an underlying infection or inflammatory process.
After assessing Mr. B, what is the initial action of the nurse?
- A. Immediately place the client in a negative-pressure room
- B. Set the client up to receive a bronchoscopy
- C. Contact the physician for antifungal medications
- D. Administer oxygen and assist the client to sit in the semi-Fowler's position
Correct Answer: A
Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.
A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select one that doesn't apply.
- A. Urine specific gravity of 1.040.
- B. Urine output of 350 ml in 24 hours.
- C. Brown ("tea-colored"?) urine.
- D. Generalized edema.
Correct Answer: D
Rationale: The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.