Nokea
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
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The nurse is caring for a client with a diagnosis of chorioamnionitis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for delivery
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis requires antibiotics for infection fetal heart tone monitoring for distress and preparation for delivery (vaginal or cesarean) if maternal or fetal condition worsens. All interventions are appropriate.
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Myopia
- D. Amblyopia
Correct Answer: C
Rationale: Visual images are blurred and distorted. Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. These symptoms are classic for myopia. Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Clients with an axillopopliteal bypass graft should avoid prolonged sitting in a straight chair, as it can compress the graft and impair blood flow. Reclining, supine, or Sim’s positions are less likely to compromise the graft.
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.