Nokea
Describe nursing management of clients with impending or actual shock.
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
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What findings indicate tension pneumothorax causing mediastinal shift?
- A. Diminished breath sounds on left side; trachea deviated to right; decreasing blood pressure, increasing pulse rate
- B. Rapid, shallow respirations; trachea deviated to left; slow pulse; collapsed neck veins
- C. Dyspnea; hyperresonance on right; widened pulse pressure; rapid, bounding pulse
- D. Chest pain; cyanosis; collapsed neck veins; decreasing pulse rate
Correct Answer: A
Rationale: Tension pneumothorax causes unilateral lung collapse, mediastinal shift, hypotension, and tachycardia.
A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis. In this case, the low pH indicates acidosis, and the elevated PaCO2 indicates respiratory involvement. In respiratory acidosis, the lungs cannot eliminate enough CO2, leading to an increase in carbonic acid and a decrease in pH. Metabolic acidosis (choice A) would involve a primary decrease in bicarbonate levels, not seen in this scenario. Metabolic alkalosis (choice B) would involve an increase in bicarbonate levels, which is not indicated by the given information. Respiratory alkalosis (choice D) would have a low PaCO2 and an elevated pH, opposite of what is seen here.
A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?
- A. Administer low-flow oxygen continuously via nasal cannula.
- B. Encourage oral intake of at least 3,000 mL of fluids per day.
- C. Offer high-protein and high-carbohydrate foods frequently.
- D. Place in a prone position
Correct Answer: D
Rationale: The correct answer is D, placing the client in a prone position. This intervention optimizes oxygenation by improving ventilation-perfusion matching in ARDS. When the client is in a prone position, there is better distribution of ventilation to the dorsal lung regions, reducing the risk of ventilator-induced lung injury.
Choice A is incorrect because low-flow oxygen may not be sufficient to meet the oxygen demands of a client with ARDS. Choice B is incorrect because excessive oral intake can lead to fluid overload in ARDS. Choice C is incorrect because high-protein and high-carbohydrate foods may be difficult for the client to tolerate and can contribute to increased carbon dioxide production.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
Where was the mistake made in the nursing process with this patient?
- A. Planning
- B. Diagnosis
- C. Evaluation
- D. Assessment
Correct Answer: B
Rationale: The initial diagnosis of ineffective self-health management overlooked the financial barrier, which is a root cause rather than lack of knowledge.