Nokea
The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
- A. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
- B. 52-yr-old with a blood pressure of 198/90 mm Hg who has leg cramping
- C. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.1 mg/dL
- D. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain first because chest pain can be a sign of a cardiac issue, which could be life-threatening. Assessing this patient first is crucial to rule out any acute cardiac events. Leg cramping (choice B) is a common symptom in hypertensive patients but is not as urgent as chest pain. High creatinine levels (choice C) may indicate kidney issues but do not require immediate assessment compared to chest pain. Microalbuminuria (choice D) is a sign of kidney damage in hypertension but does not pose an immediate threat like chest pain.
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Inflammation of the lung covering causing severe chest pain is
- A. Emphysema
- B. Pleurisy
- C. Asphyxia
- D. Hypoxia
Correct Answer: B
Rationale: The correct answer is B: Pleurisy. Pleurisy is the inflammation of the lung covering (pleura), leading to severe chest pain. Emphysema (A) is a chronic lung disease characterized by damaged air sacs. Asphyxia (C) is a condition of inadequate oxygen supply. Hypoxia (D) is a state of low oxygen levels in tissues. Pleurisy is the best fit as it directly relates to inflammation of the lung covering and severe chest pain.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.
When the diaphragm and external intercostals muscles contract, which of the following actions does NOT occur?
- A. air moves into the lung
- B. the intrapleural pressure increases
- C. the diaphragm moves inferiorly
- D. the intrapulmonary pressure decreases
Correct Answer: B
Rationale: When the diaphragm and external intercostals contract, the thoracic cavity expands, causing the lungs to expand and the intrapulmonary pressure to decrease (choice D). This decrease in pressure allows air to flow into the lungs (choice A). The diaphragm moves inferiorly during contraction, not superiorly (choice C). The intrapleural pressure actually decreases when these muscles contract, not increases, due to increased thoracic volume and decreased intrapleural pressure acting as a suction to keep the lungs inflated (choice B). Therefore, the correct answer is B, as the intrapleural pressure actually decreases when the diaphragm and external intercostals contract.
Which assessment findings aren't consistent with a client diagnosis of right-sided heart failure?
- A. Collapsed neck veins
- B. Distended abdomen
- C. Dependent edema
- D. Decreased appetite
Correct Answer: A
Rationale: The correct answer is A because collapsed neck veins are not consistent with right-sided heart failure. In right-sided heart failure, venous congestion leads to jugular venous distention, not collapse. Distended abdomen (choice B) occurs due to fluid accumulation in the abdomen, a common finding in right-sided heart failure. Dependent edema (choice C) results from fluid retention in the lower extremities, also seen in right-sided heart failure. Decreased appetite (choice D) can be present due to abdominal discomfort from fluid accumulation. Therefore, the presence of collapsed neck veins is the only assessment finding that is not indicative of right-sided heart failure.
The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that
the level of drainage has not increased over the last 3 hours. After assessing the patient’s
respiratory status, what should the nurse do next?
- A. Raise the system above the patient's heart.
- B. Check the tubing for kinks.
- C. Reposition the patient.
- D. Notify the physician.
Correct Answer: B
Rationale: The correct answer is B: Check the tubing for kinks. This is the best next step because stagnant drainage could be caused by a kink in the tubing, obstructing proper drainage. By checking for kinks, the nurse ensures proper functioning of the drainage system, preventing potential complications such as fluid buildup or infection.
Raising the system above the patient's heart (A) may not address the underlying issue of kinked tubing. Repositioning the patient (C) may not be necessary if the drainage is not related to patient positioning. Notifying the physician (D) should be done after checking the tubing for kinks, as it is important to troubleshoot and address the issue promptly.