Nokea
Stephen Douglas has been in an automobile accident. The most effective IV solution for a patient having hypovolemic shock would be:
- A. hypertonic.
- B. isotonic.
- C. hypotonic.
- D. colloids.
Correct Answer: B
Rationale: Hypertonic IV fluids would be used to draw fluid off tissue in edematous situations such as third spacing. Isotonic solutions are used to increase intravascular volume, to increase perfusion of vital organs. Hypotonic fluids are used to rehydrate tissue in those with severe, or prolonged fluid deprivation. Colloids increase tonicity of intravascular fluids, pulling water into the vascular system from tissue.
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While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues.
A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery.
C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period.
D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.
What considerations and interventions should be used when caring for a client with a hearing impairment?
- A. Use written communication
- B. Speak loudly and slowly
- C. Provide visual aids
- D. All of the above
Correct Answer: D
Rationale: Using multiple strategies ensures effective communication and accommodation for the client's needs.
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
Tom reports a history of carpal tunnel syndrome. What else would you expect to find in his history?
- A. Crepitus (grating feeling on palpation over joint during range of motion) due to loss of articular cartilage and bony overgrowth in joint.
- B. Excessive forward curvature of the thoracic spine (kyphosis) due to pathologic vertebral fractures and collapsing of the anterior portion of the vertebral bodies in the thoracic area.
- C. Pain and numbness or tingling sensation in the hand over the palmar surface of the thumb, index, and middle fingers, and lateral aspect of the ring finger, that is worse at night.
- D. Acute onset of excruciating pain in joint due to accumulation of uric acid within the joint.
Correct Answer: C
Rationale: Carpal tunnel syndrome affects the median nerve, causing pain and numbness in specific areas.