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The nurse is assisting with the care of a client who sustained a cervical spinal cord injury 1 hour ago and has paralysis in all four extremities. Which of the following actions would be a priority for the nurse to take?
- A. Reposition the client every 2 hours.
- B. Monitor the client for autonomic dysreflexia.
- C. Check the client's respiratory status frequently
- D. Perform passive range-of-motion exercises every 4 hours.
Correct Answer: C
Rationale: Respiratory status (C) is the priority in acute cervical spinal cord injury due to risk of respiratory failure. Repositioning (A), dysreflexia monitoring (B), and exercises (D) are secondary.
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Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
- A. Massage the abdomen gently.
- B. Reduce the amount of irrigation solution.
- C. Increase his oral intake.
- D. Place a heating pad on the abdomen.
Correct Answer: A
Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.