Nokea
The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?
- A. The client has asymmetrical chest expansion
- B. Percussion reveals dullness over the lung area
- C. Bilateral breath sounds can be auscultated
- D. The client has been turned q2h
Correct Answer: C
Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.
You may also like to solve these questions
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Ensure that the knot can be quickly released.
- B. Tie the knot with a double turn or square knot.
- C. Move the ties so the restraints are secured to the side rails.
- D. Ensure that the restraints are snug against the client's wrist.
Correct Answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.
After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
- A. Perform a finger stick glucose test
- B. Increase the IV fluid flow rate
- C. Review 24-hour intake and output
- D. Obtain arterial blood gases
Correct Answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide?
- A. All future children will be carriers, but will not necessarily have the disease
- B. There is a chance that each future child will have the disease
- C. Only male children cannot inherit the sickle cell disease trait
- D. Only one out of four of their children will definitely manifest the disease
Correct Answer: B
Rationale: The correct answer is B. Each child has a 25% chance of having sickle cell anemia if both parents are carriers of the trait. Choice A is incorrect because not all future children will be carriers; some may have the disease. Choice C is incorrect as both male and female children can inherit the sickle cell disease trait. Choice D is incorrect as the chance is not fixed at one out of four; each child has an independent 25% chance of having the disease.
An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor signs of increased bleeding
- B. Instruct on the use of incentive spirometry
- C. Observe for confusion and restlessness
- D. Administer intravenous opioids for severe pain
Correct Answer: A
Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.
What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?
- A. Assess IV site frequently for signs of extravasation
- B. Monitor capillary refill distal to the infusion site
- C. Apply a topical anesthetic at the infusion site for burning
- D. Explain that temporary burning at the IV site may occur
Correct Answer: A
Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.