Nokea
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
- A. Bronchial breath sounds in outer lung fields
- B. Decreased tactile fremitus
- C. Hacking, nonproductive cough
- D. Hyper-resonance of areas of consolidation
Correct Answer: A
Rationale: Bronchial breath sounds in outer lung fields. Consolidated lung tissue in pneumonia transmits bronchial breath sounds to outer lung fields.
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A patient is being treated in the telemetry unit for cardiac disease. The patient is to receive propranolol hydrochloride (Inderal) 20 mg PO at 9 AM. The nurse finds him wheezing with a nonproductive cough and shortness of breath.
INITIALLY, the nurse should
- A. hold the medication and count the respirations.
- B. hold the medication and call the physician.
- C. take an apical pulse and then give the medication.
- D. give the medication as ordered.
Correct Answer: A
Rationale: Strategy: Determine the outcome of each answer choice. (1) correct-side effects include increased airway resistance, patient is experiencing bronchospasm, should assess then call the physician (2) should assess the patient's condition first (3) experiencing a side effect, medication should not be given (4) medication should be held, experiencing a side effect
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Heart rate of 80 bpm.
- C. Blood pressure of 120/80 mmHg.
- D. Temperature of 99.5°F (37.5°C).
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
- A. A postoperative appendectomy client who is complaining of incisional pain.
- B. A diabetic client who had a cardiac catheterization in the early AM.
- C. A postoperative cholecystectomy client who is complaining of incisional pain.
- D. A client with congestive heart failure who underwent diuresis in the hospital.
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
A 48-year-old woman is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor the patient's
- A. complete blood count (CBC).
- B. temperature.
- C. specific gravity of urine.
- D. intracranial pressure.
Correct Answer: C
Rationale: Transsphenoidal hypophysectomy risks diabetes insipidus from ADH disruption, detected by low urine specific gravity. Options A, B, and D are less specific.