Nokea
The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?
- A. Frothy hemoptysis
- B. Trachea shift toward the unaffected side of the chest
- C. Subcutaneous emphysema noted at the anterior chest
- D. Opening chest wound with a whistle sound emitting from the area
Correct Answer: B
Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.
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A 19-year-old male with type 1 diabetes has the flu. The nurse expects what insulin changes may be required during the illness?
- A. stopping all insulin
- B. needing more insulin
- C. needing less insulin
- D. using the same amount of insulin
Correct Answer: B
Rationale: Illness increases insulin resistance due to stress hormones, often requiring more insulin to manage hyperglycemia in type 1 diabetes.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.
Which type of leukemia is more common in older adults?
- A. Acute myelocytic leukemia
- B. Acute lymphocytic leukemia
- C. Chronic lymphocytic leukemia
- D. Chronic granulocytic leukemia
Correct Answer: C
Rationale: Chronic lymphocytic leukemia (CLL) is most common in older adults, typically diagnosed in those over 60, due to its indolent nature and prevalence in this age group.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
- A. Mild nausea.
- B. Hot flashes.
- C. Vaginal bleeding.
- D. Hair thinning.
Correct Answer: C
Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer
The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
- A. Ineffective airway clearance
- B. Impaired gas exchange
- C. Fluid volume deficit
- D. Pain
Correct Answer: C
Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.