Nokea
For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death.
- A. Respiratory: Cheyne-Stokes respirations
- B. Skin: Mottling
- C. Gastrointestinal: Loss of appetite
- D. Musculoskeletal: Weakness
Correct Answer:
Rationale:
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Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called:
- A. Craving.
- B. Crashing.
- C. Outward bound.
- D. Nodding out.
Correct Answer: B
Rationale: Crashing refers to the intense fatigue and depression following cocaine use.
What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU?
- A. Monitoring arterial blood gases
- B. Electrocardiographic (ECG) monitoring
- C. Determining fluid and electrolyte status
- D. Direct arterial blood pressure monitoring
Correct Answer: B
Rationale: ECG monitoring assesses cardiovascular function, detecting arrhythmias or ischemia.
Alex Rowe develops hives after having eaten strawberries. He states he has strawberries before, and has never had a problem with them before. This is an example of:
- A. an idiosyncratic response to food.
- B. an autoimmune disorder.
- C. a Type I hypersensitivity response.
- D. an example of immunosuppression.
Correct Answer: C
Rationale: Idiosyncratic response means it occurs because of an unknown reason. This response to something the body has been exposed to before is not unknown. Autoimmune disorders are ones in which the body attacks self-cells. This example is an outside antigen. Type I hypersensitivities are those that occur when the body, previously sensitized to a substance, is then exposed a second time and reacts. Immunossuppression occurs when the immune system is not working. Mr. Rowe's immune system responded to the antigen, so it is not suppressed.
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
- A. Increase the wall suction.
- B. Strip the chest tube.
- C. Clamp the chest tube.
- D. Reposition the client.
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct Answer: C
Rationale: Step 1: Checking the oximeter is essential to assess the client's oxygen saturation levels immediately post-procedure.
Step 2: Hypoxia can lead to serious complications, impacting the client's neurological status.
Step 3: The nurse must prioritize oxygenation status to prevent further brain injury or hypoxemia.
Step 4: Observing for CSF leaks, assessing temperature, and monitoring ICP are important but not as immediate as ensuring adequate oxygen supply.
Summary: Option C is correct as it addresses the most critical and immediate concern post-procedure, ensuring optimal oxygenation for the client's neurological recovery. Options A, B, and D are important but secondary to maintaining oxygen levels.