Nokea
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
- A. Place the client in the Trendelenburg position
- B. Contact the physician for an order for antibiotics
- C. Administer oxygen therapy
- D. Decrease his IV rate
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.
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The nurse is teaching a client the proper technique for using a cane. Which statements should the nurse include in the teaching? Select all that apply.
- A. Hold the cane on the affected side.
- B. Hold the cane on the unaffected side.
- C. Move the cane at the same time as the affected leg.
- D. Move the cane at the same time as the unaffected leg.
- E. Hold the cane 8 to 10 inches from the side of the foot.
Correct Answer: B,C
Rationale: The cane is held on the unaffected side and moved with the affected leg to provide support. The cane is held closer to the body, not 8-10 inches away.
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
- A. Ask the client to raise the forearm above the head.
- B. Have the client spread all of the fingers wide and resist pressure.
- C. Ask the client to move the thumb toward the palm and then back to the neutral position.
- D. Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers.
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
- A. Inhales slowly
- B. Breathes through the nose
- C. Removes the mouthpiece to exhale
- D. Forms a tight seal around the mouthpiece with the lips
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?
- A. Variable decelerations
- B. Late decelerations
- C. Early decelerations
- D. Accelerations
Correct Answer: B
Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
- A. Cleanse the perineal area with soap and water once a day.
- B. Keep the drainage bag lower than the level of the bladder.
- C. Limit fluid intake so that the bag will not become full so quickly.
- D. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.