Nokea
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
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Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
A primigravid client at 38 weeks' gestation reports decreased fetal movement. What is the nurse's first action?
- A. Perform a nonstress test.
- B. Notify the physician.
- C. Encourage the client to drink water.
- D. Auscultate fetal heart tones.
Correct Answer: D
Rationale: Auscultating fetal heart tones is the first step to assess fetal well-being in response to decreased movement, providing immediate data.
A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
- A. Allen test
- B. Turner's sign
- C. Babinski reflex
- D. Brudzinski's sign
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
- A. Administer regular insulin as prescribed.
- B. Restrict fluid intake.
- C. Encourage a high-carbohydrate diet.
- D. Administer glucagon.
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.