Nokea
The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a "crackling" noise with palpation. The nurse should further assess the client for which of the following problems?
- A. Flail chest
- B. Subcutaneous emphysema
- C. Infiltrated subclavian IV
- D. Pneumothorax
Correct Answer: B
Rationale: Puffy skin and crackling (crepitus) over the clavicle suggest subcutaneous emphysema, where air escapes into tissues, often with rib fractures. Flail chest (A) involves paradoxical chest movement, infiltrated IV (C) is unrelated, and pneumothorax (D) causes absent breath sounds.
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A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: D
Rationale: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?
- A. Blood pressure of 150/100
- B. 2+ proteinuria
- C. Absence of deep tendon reflexes
- D. Edema of the lower extremities
Correct Answer: C
Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which physician's order should the nurse question?
- A. Magnesium sulfate 4 gm (25\%) IV
- B. Brethine (terbutaline) 10 mcg IV
- C. Stadol (butorphanol) 1mg IV push every four hours as needed PRN for pain
- D. Ancef (cefazolin) 2 gm IVPB every six hours
Correct Answer: B
Rationale: Terbutaline (Brethine) a tocolytic is used to stop preterm labor but is contraindicated in diabetic patients due to its risk of causing hyperglycemia. The other medications are appropriate for preeclampsia (magnesium sulfate) pain (butorphanol) or infection prophylaxis (cefazolin).
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.