Nokea
The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply.
- A. Dyspnea
- B. Cyanosis
- C. Tachypnea
- D. Kussmaul's respiration
- E. Irregular respiratory pattern
- F. Adventitious bubbling lung sounds
Correct Answer: A,B,E,F
Rationale: Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing.
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The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
- A. Stop movement of the affected part.
- B. Massage the affected part vigorously.
- C. Notify the primary health care provider immediately.
- D. Force movement of the joint supporting the muscle.
- E. Ask the client to stand and walk rapidly around the room.
- F. Place continuous gentle pressure on the muscle group until it relaxes.
Correct Answer: A,F
Rationale: ROM exercises should put each joint through as full a range of motion as possible without causing discomfort. An unexpected outcome is the development of spastic muscle contraction during ROM exercises. If this occurs, the nurse should stop movement of the affected part and place continuous gentle pressure on the muscle group until it relaxes. Once the contraction subsides, the exercises are resumed using slower, steady movement. Massaging the affected part vigorously may worsen the contraction. There is no need to notify the primary health care provider unless intervention is ineffective. The nurse should never force movement of a joint. Asking the client to stand and walk rapidly around the room is an inappropriate measure.
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
- A. Hypotension
- B. Photophobia
- C. Profuse sweating
- D. Decrease in urine output
Correct Answer: D
Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. None of the other options are associated with an adverse reaction to this medication.
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.