Nokea
The nurse is auscultating the lungs in a postoperative client and hears something that sounds like a cellophane bag being wrinkled when the client takes in a breath. How should the nurse record this finding?
- A. Crackles
- B. Stridor
- C. Stertor
- D. Wheezes
Correct Answer: A
Rationale: Crackles, sounding like crinkling cellophane, indicate fluid in alveoli or airway collapse, common post-surgery. Stridor, stertor, and wheezes have different characteristics.
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The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.
The doctor has prescribed imipramine (Tofranil) for an elderly client with endogenous depression. The nurse should give priority to assessing the client's:
- A. Fluid intake
- B. Cardiac status
- C. Respiratory effort
- D. Urinary output
Correct Answer: B
Rationale: Imipramine, a tricyclic antidepressant, can cause cardiac arrhythmias, especially in the elderly, making cardiac status assessment a priority.
The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?
- A. Blood in nasogastric tube drainage
- B. Decrease in red blood cell count
- C. Increase in serum creatinine level
- D. Onset of muscle aches and cramping
Correct Answer: C
Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
- A. Arterial septal defect
- B. Patent ductus arteriosus
- C. Aortic stenosis
- D. Ventricular septal defect
Correct Answer: D
Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.
A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to
- A. add dietary fiber
- B. reduce ammonia levels
- C. stimulate peristalsis
- D. control portal hypertension
Correct Answer: B
Rationale: Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.