Nokea
The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock?
- A. Reflexes
- B. Pulse rate
- C. Temperature
- D. Blood pressure
Correct Answer: A
Rationale: Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery.
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The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
- A. Takes blood pressures in the right arm only
- B. Draws serum laboratory samples from the right arm only
- C. Positions the client supine and flat with the right arm elevated on a pillow
- D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D
Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.
A client has been taking a prescribed calcium channel blocker therapy for approximately 2 months. The home care nurse monitoring the effects of therapy should determine that drug tolerance has developed if which is noted in the client?
- A. Decrease in weight
- B. Increased joint pain
- C. Output greater than intake
- D. Gradual rise in blood pressure
Correct Answer: D
Rationale: Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. Joint pain is not associated with this form of tolerance.
The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information should the nurse share with the client about the therapy?
- A. After the initial dose, subsequent treatments must continue lifelong.
- B. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose.
- C. It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease.
- D. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.
Correct Answer: C
Rationale: Graves' disease is also known as toxic diffuse goiter and is characterized by a hyperthyroid state resulting from hypersecretion of thyroid hormones. After treatment with radioactive iodine therapy, a decrease in the thyroid hormone level should be noted, which helps alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. Occasionally, a client may require a second or third dose, but treatments are not lifelong. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse must reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates.
A client has a prescription to receive an enema before bowel surgery. The nurse assists the client into which position to administer the enema?
- A. enema_1.PNG
- B. enema_2.PNG
- C. enema_3.PNG
- D. enema_4.PNG
Correct Answer: C
Rationale: When administering an enema, the nurse places the client in a Sims' position (option 3) exposing the rectal area and allowing the enema solution to flow by gravity in the natural direction of the colon. In the prone position (option 1), the client is lying on the stomach. In the supine position (option 2), the client is lying on the back. The dorsal recumbent position (option 4) is used for abdominal assessment because it promotes relaxation of abdominal muscles.
The nurse is assisting a client with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse should take which action to minimize the client's risk for injury?
- A. Clamp the chest tube.
- B. Call the primary health care provider.
- C. Apply a petroleum gauze over the end of the chest tube.
- D. Immerse the chest tube in a bottle of sterile water or normal saline.
Correct Answer: D
Rationale: If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube or, in this case, immersing the end of the chest tube 1 to 2 inches below the surface of a 250-mL bottle of sterile water or normal saline until a new chest tube can be set up. The primary health care provider should be notified but only after taking corrective action. If the primary health care provider is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petroleum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.