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Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication?
- A. Gastrointestinal bleeding.
- B. Myocardial infarction.
- C. Emesis.
- D. Rib fracture.
Correct Answer: D
Rationale: Incorrect hand placement during CPR can cause rib fractures, which, while sometimes unavoidable, can be minimized with proper technique, such as placing hands at the center of the chest over the lower half of the sternum.
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A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
- A. Percuss the abdomen to note resonance and tympany.
- B. Percuss the liver to note lack of dullness.
- C. Monitor the vital signs for fever, tachypnea, and bradycardia.
- D. Assess presence of polyphagia and polydipsia.
- E. Auscultate bowel sounds to note frequency.
Correct Answer: B,C
Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze
What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
The nurse is caring for a client taking a prescribed naproxen. The nurse should assess the client for which adverse effect?
- A. Low blood glucose
- B. Agitation
- C. Bleeding
- D. Nasal congestion
Correct Answer: C
Rationale: Naproxen, an NSAID, can cause gastrointestinal bleeding due to its inhibition of platelet aggregation and mucosal irritation.
The nurse should assess an older adult with macular degeneration for:
- A. Loss of central vision.
- B. Loss of peripheral vision.
- C. Total blindness.
- D. Blurring of vision.
Correct Answer: A
Rationale: Macular degeneration primarily affects the macula, leading to loss of central vision, which impairs activities like reading and recognizing faces.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
- A. Normal breath sounds.
- B. Prolonged inspiration.
- C. Normal chest movement.
- D. Coarse crackles and rhonchi.
Correct Answer: D
Rationale: COPD exacerbation with infection produces coarse crackles and rhonchi from secretions and airway inflammation. Breath sounds are diminished, expiration is prolonged, and chest movement is reduced.