Nokea
The nurse is caring for a client who has a pulmonary embolism. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dyspnea
- B. chest pain
- C. tachypnea
- D. hypoxemia
- E. bradycardia
- F. tracheal deviation
Correct Answer: A,B,C,D
Rationale: Pulmonary embolism obstructs pulmonary arteries, causing dyspnea, chest pain, tachypnea, and hypoxemia. Bradycardia is unlikely; tachycardia is typical. Tracheal deviation is associated with tension pneumothorax, not embolism.
You may also like to solve these questions
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.
Which client would be at greatest risk for a fat emboli following a fracture?
- A. A 50-year-old with a fractured fibula
- B. A 20-year-old female with a wrist fracture
- C. A 21-year-old male with a fractured femur
- D. An 8-year-old with a fractured arm
Correct Answer: C
Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.
The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Anticipate ear pain and give acetaminophen as needed
- B. Educate parents to expect the child to develop bad breath postoperatively
- C. Encourage the child to drink cold liquids through a straw
- D. Notify the health care provider about frequent, increased swallowing
- E. Use an oral suction device regularly to remove secretions from the back of the throat
Correct Answer: A,B,D
Rationale: Ear pain is common post-tonsillectomy due to referred pain, treated with acetaminophen. Bad breath is expected from healing tissue. Frequent swallowing may indicate bleeding, requiring provider notification. Cold liquids are soothing but straws risk trauma. Routine suctioning is unnecessary and risky.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.