Nokea
The nurse is performing an assessment on a client with a history of a tension pneumothorax. Which finding is most concerning?
- A. Tracheal deviation
- B. Chest pain
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Tracheal deviation in a tension pneumothorax indicates mediastinal shift from increased intrathoracic pressure, a life-threatening emergency requiring immediate attention.
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A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.
Which of the following activities have been associated with an increase in lead exposure?
- A. Working with stained glass
- B. Drinking from disposable water bottles
- C. Restoring collectible toys
- D. Drinking coffee and tea from decorative ceramic mugs
- E. Using non-stick cookware
- F. Residing in a home constructed before 1950
Correct Answer: A, C, D, F
Rationale: Lead exposure risks include stained glass work (A), restoring old toys (C), decorative mugs (D), and pre-1950 homes (F) due to lead-based paint or glazes. Disposable bottles (B) and non-stick cookware (E) are not significant sources.
Which newborn assessment is considered an abnormal finding that requires immediate attention?
- A. Cyanosis of the hands and feet
- B. Umbilical stump with three vessels
- C. Jitteriness and shaking
- D. Presence of harlequin sign
Correct Answer: C
Rationale: Jitteriness and shaking in a newborn may indicate hypoglycemia seizures or neurological issues requiring immediate attention. Cyanosis of hands and feet (acrocyanosis) three umbilical vessels and harlequin sign are normal or benign findings.
A nurse should carefully monitor a client for the following side effect of MgSO4:
- A. Visual blurring
- B. Tachypnea
- C. Epigastric pain
- D. Respiratory depression
Correct Answer: D
Rationale: The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. This is the opposite side effect of this medication. This is a common side effect of this medication and needs to be monitored and recorded frequently.
After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
- A. Lorazepam (Ativan)
- B. Benztropine (Cogentin)
- C. Thiothixene (Navane)
- D. Flurazepan (Dalmane)
Correct Answer: B
Rationale: Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site.