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For a client with sickle cell anemia, how does the nurse assess for jaundice?
- A. The nurse assesses mental status, verbal ability, and motor strength
- B. The nurse observes the joints for signs of swelling
- C. The nurse inspects the skin and sclera for jaundice
- D. The nurse collects a urine specimen
Correct Answer: C
Rationale: The correct answer is C because jaundice is a common manifestation of sickle cell anemia due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for the characteristic yellow discoloration indicating jaundice. This assessment is specific to identifying jaundice, which is directly related to the disease process.
Choice A is incorrect as it relates to assessing neurological function, not jaundice. Choice B is incorrect as joint swelling is not a typical sign of jaundice in sickle cell anemia. Choice D is incorrect as a urine specimen is not used to assess jaundice; skin and sclera inspection are more appropriate.
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A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
- A. Indwelling urinary catheter kit
- B. Cardiac monitor
- C. Tracheostomy set
- D. Humidifier
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set
Rationale:
1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway.
2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention.
3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment.
Summary of other choices:
A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care.
B: Cardiac monitor - Important but secondary to airway management in this situation.
D: Humidifier - Not essential for immediate post-thyroidectomy care.
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in 8 hours
- B. Respiratory rate of 8breaths/min
- C. Irregular heart rate of 82 beats/min
- D. Pupils constricted and equal A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET J
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest.
A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding.
C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically.
D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain.
Summary of other choices:
B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location.
C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain.
D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis.
Explanation of other choices:
B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect.
C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location.
D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
- A. Above-normal urine and serum osmolality levels
- B. Below-normal urine and serum osmolality levels
- C. Above-normal urine osmolality level, below-normal serum osmolality level
- D. Below- normal urine osmolality level, above-normal serum osmolality level
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus.
Explanation for other choices:
A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus.
B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus.
C: Above-normal urine osmolality level, below-normal