Nokea
The client develops a tension pneumothorax. Assessment is expected to reveal?
- A. Sudden hypertension and bradycardia
- B. Productive cough with yellow mucus
- C. Tracheal deviation and dyspnea
- D. Sudden development of profuse hemoptysis and weakness
Correct Answer: C
Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (Choice A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (Choice B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (Choice D) is not characteristic of tension pneumothorax presentation.
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A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
- A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
- B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
- C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
- D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.
Correct Answer: C
Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary
Correct Answer: D
Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
- A. cor pulmonale.
- B. atelectasis.
- C. pulmonary embolism.
- D. cardiac tamponade.
Correct Answer: B
Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.
While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
- A. Aspirate the IV site for blood return.
- B. Slow the infusion.
- C. Inspect the IV site.
- D. Stop the infusion.
Correct Answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?
- A. Engage the client to walk with you to make another pot of coffee
- B. Ask the client to reflect on their behavior to determine if it is appropriate
- C. Ask the group to tell the client how they feel when she interrupts
- D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy
Correct Answer: A
Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.