Nokea
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.
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A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What should the nurse monitor to determine the presence of carbon monoxide poisoning?
- A. Pulse oximetry
- B. Urine myoglobin
- C. Sputum carbon levels
- D. Serum carboxyhemoglobin levels
Correct Answer: D
Rationale: Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen under pressure (hyperbaric oxygen therapy). Options 1, 2, and 3 would not identify carbon monoxide poisoning.
A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse should assess for which expected but adverse effect of PEEP?
- A. Decreased peak pressure on the ventilator
- B. Increased rectal temperature from 98°F to 100°F
- C. Decreased heart rate from 78 to 64 beats per minute
- D. Systolic blood pressure decrease from 122 to 98 mm Hg
Correct Answer: D
Rationale: PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.
The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
- A. Hypotension
- B. Photophobia
- C. Profuse sweating
- D. Decrease in urine output
Correct Answer: D
Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. None of the other options are associated with an adverse reaction to this medication.