Nokea
The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
- A. O2 saturation is 88%
- B. Blood pressure is 155/90 mm Hg.
- C. Respiratory rate is 24 breaths/min when lying flat.
- D. Pain level is 5 (on 0 to 10 scale) with a deep breath.
Correct Answer: A
Rationale: The correct answer is A because a low O2 saturation level (88%) indicates potential respiratory compromise or hypoxemia post-thoracentesis, which requires immediate intervention to prevent hypoxia. The other choices are not as critical: B (BP slightly elevated but not urgent), C (RR slightly elevated but expected after procedure), and D (Pain at level 5 with deep breath is common post-thoracentesis and can be managed).
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For a male client with an endotracheal (ET) tube, which nursing action is most essential?
- A. Auscultating the lungs for bilateral breath sounds.
- B. Turning the client from side to side every 2 hours.
- C. Monitoring serial blood gas values every 4 hours.
- D. Providing frequent oral hygiene.
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed.
Summary:
- Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds.
- Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement.
- Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
- A. Urine output is 500 mL during an 8-hour shift.
- B. Tremors are noted in the fingers when the patient extends the arms.
- C. The client reports a headache with pain at level 7
- D. The client cannot move the left arm when asked to do so.
Correct Answer: D
Rationale: The correct answer is D because the inability to move the left arm could indicate a neurological deficit or stroke, which is a critical finding that requires immediate medical attention in a hypertensive emergency. This could indicate a potential life-threatening condition that needs urgent intervention to prevent further complications.
A: Urine output is important but not as critical as potential neurological deficits in this scenario.
B: Tremors in the fingers are concerning but not as urgent as a potential neurological deficit.
C: Headache at level 7 is significant but not as critical as a neurological deficit that could indicate a stroke.
Each of the following is true regarding the spleen, except:
- A. Spleen is located posterolateral to the stomach, and contacts the diaphragm and left kidney.
- B. Splenic veins, arteries, and lymphatic vessels communicate with the spleen at the hilum.
- C. The spleen is a primary lymphoid organ, serving to filter lymph fluid.
- D. Lymphocytes and dendritic cells are concentrated in the white pulp.
Correct Answer: C
Rationale: Rationale:
C is correct because the spleen is a secondary lymphoid organ, not a primary one. The spleen filters blood, not lymph fluid.
A is correct as the spleen is located in the described position.
B is correct as the splenic vessels do communicate with the spleen at the hilum.
D is correct as lymphocytes and dendritic cells are indeed concentrated in the white pulp.
Summary:
A, B, and D are correct statements about the spleen. C is incorrect because the spleen is a secondary lymphoid organ, not a primary one.
Internal intercostal muscles are used in ...
- A. inspiration
- B. expiration
- C. both of them
- D. pause
Correct Answer: B
Rationale: The correct answer is B: expiration. The internal intercostal muscles are used during expiration to decrease the size of the thoracic cavity, increasing the pressure in the lungs, causing air to be pushed out. During inspiration, the external intercostal muscles are used to expand the thoracic cavity. Choice A is incorrect as it refers to inspiration. Choice C is incorrect because internal intercostal muscles are not involved in both inspiration and expiration simultaneously. Choice D is incorrect as there is no specific muscle action associated with a "pause" in breathing.
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
- A. Tell the client that he needs to quit smoking to stop further cancer development.
- B. Encourage the client to be completely honest about both tobacco and marijuana use.
- C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
- D. Avoid giving the client false hope regarding cancer treatment and prognosis.
Correct Answer: C
Rationale: Rationale:
C is correct as maintaining a nonjudgmental attitude is crucial to establish trust and rapport with the client. It helps the client feel comfortable sharing information, leading to better assessment and care. A is incorrect as quitting smoking may not be the immediate priority. B is incorrect as honesty about marijuana use is not the primary concern. D is incorrect as it does not address the importance of establishing a therapeutic relationship.