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The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.
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A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.
The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?
- A. Contractions of the sternocleidomastoid muscle.
- B. Respiratory rate of 20 breaths/min
- C. Downward movement of diaphragm with inspiration
- D. A pulse oximetry reading of SpO2 95%
Correct Answer: A
Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.
When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?
- A. Hold the thermometer in place.
- B. Place the disposable pad under the buttocks.
- C. Instruct the client to breathe deeply.
- D. Return the probe to the charger.
Correct Answer: A
Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.
A client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?
- A. Increased joint pain
- B. Weight gain of 2 pounds in 24 hours
- C. Blood glucose level of 150 mg/dl
- D. Fever of 100.4°F
Correct Answer: B
Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.
An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?
- A. Addiction
- B. Phobia
- C. Compulsion
- D. Obsession
Correct Answer: C
Rationale: The client's handwashing ritual is a compulsion, a repetitive behavior driven by the need to reduce anxiety associated with an obsession. In this case, the client's need to wash her hands excessively stems from an obsession with cleanliness, leading to the compulsive behavior of extensive handwashing. 'Addiction' (Choice A) involves a dependence on a substance or behavior, not related to this scenario. 'Phobia' (Choice B) is an intense fear of a specific object or situation, not applicable here. 'Obsession' (Choice D) refers to persistent and intrusive thoughts, while the handwashing behavior in this case is the compulsive action taken to alleviate the anxiety related to the obsession.