Nokea
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. A left hemothorax
- B. A right hemothorax
- C. Intubation of the right mainstem bronchus
- D. An inadequate mechanical ventilator
Correct Answer: C
Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.
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The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement every thirty minutes
Correct Answer: B
Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child's behavior is:
- A. The child did not want a sibling.
- B. The child was not adequately prepared for the baby's arrival.
- C. The child's daily routine has been upset by the birth of his sister.
- D. The child is just trying to get the parent's attention.
Correct Answer: C
Rationale: Children with autism often rely on structured routines, and disruptions, such as a new sibling, can lead to behavioral changes due to difficulty adapting to change.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
Which client should be assigned to the nursing assistant?
- A. The 18-year-old with a fracture to two cervical vertebrae
- B. The infant with meningitis with a temperature of 101°F
- C. The elderly client with a thyroidectomy four days ago
- D. The client with a thoracotomy two days ago
Correct Answer: C
Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).
Which of the following nursing diagnoses is of highest priority for the patient with hypothyroidism?
- A. Impaired physical mobility
- B. Hypothermia
- C. Disturbed thought processes
- D. Decreased cardiac output
Correct Answer: D
Rationale: Hypothyroidism reduces metabolic rate potentially decreasing cardiac output which can lead to life-threatening complications like heart failure. While hypothermia and other diagnoses are relevant decreased cardiac output is the most critical.