Nokea
The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct Answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
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Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
- A. Stay with the client, remove the dressing, and elevate the head of bed.
- B. Call a code, open the trach set, and position the client supine.
- C. Have the client say "EEE"? to check for laryngeal integrity.
- D. Immediately go to the nurse's station and call the physician
Correct Answer: A
Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.
A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values?
pH- 7.49
Bicarbonate ion 24 mEq/dl
PaCO2 - 31 mmHg
PaO2 - 52 mmHg
FiO2 - 0.22
- A. respiratory acidosis
- B. respiratory alkalosis
- C. metabolic acidosis
- D. metabolic alkalosis
Correct Answer: B
Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.
The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not "Jesus"?.
- D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct Answer: A
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
To determine the standards of care for the institution, the nurse should consult?
- A. Organizational Chart
- B. Personnel policies
- C. Policies and procedure manual
- D. Job descriptions
Correct Answer: C
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.