Nokea
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
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A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
Which of the following actions should the nurse take?
- A. Place the oxygen tank away from curtains or drapes.
- B. Store extra oxygen tanks in a closed closet.
- C. Lay the oxygen tank on its side when not in use.
- D. Increase the oxygen flow rate if the client reports shortness of breath.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Placing the oxygen tank away from curtains or drapes reduces the risk of fire hazards since oxygen supports combustion. This action ensures a safe environment for the client.
Summary:
B: Storing extra oxygen tanks in a closed closet is a good practice, but not directly related to immediate safety concerns like fire hazards.
C: Laying the oxygen tank on its side when not in use can cause damage to the tank and is not a safe storage method.
D: Increasing the oxygen flow rate without proper assessment can be dangerous and may worsen the client's condition.
A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.