Nokea
The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
- A. Heart rate of 120 bpm.
- B. Respiratory rate of 20 breaths/min.
- C. Oxygen saturation of 95%.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.
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A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
- B. An elderly man admitted 4 hours ago with status asthmaticus.
- C. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
- D. A middle-aged woman who suffered a myocardial infarction (MI) 3 days ago.
Correct Answer: B
Rationale: Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turn patient as ordered (2) correct-life-threatening condition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking, reduce stress, modify intake of calories, fat, and salt)
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 150 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Chest tube drainage of 150 mL/hour is excessive post-CABG, suggesting hemorrhage, requiring immediate evaluation. Options A, B, and D are less concerning: heart rate 100 bpm and temperature 100.8°F are common, and blood pressure 130/80 mmHg is normal.