Nokea
The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up?
- A. Wheezes arise from the small airways and usually do not clear with coughing.
- B. A pleural friction rub causes loud, rough, scratching sounds usually during inspiration.
- C. Thick, tenacious secretions that clear with coughing cause crackles.
- D. Fluid or secretions in large airways typically cause coarse crackles.
Correct Answer: C
Rationale: Crackles are caused by air moving through fluid in small airways and do not typically clear with coughing. Other statements are accurate.
You may also like to solve these questions
The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply.
- A. I should open sterile packages away from my body.
- B. If the sterile field gets contaminated, I should dispose of everything and start over.
- C. One inch (2.5 cm) border around a sterile drape can be touched with clean fingers.
- D. I should apply sterile gloves on my non-dominant hand first.
- E. An object placed below my waist is considered contaminated.
Correct Answer: A,B,D,E
Rationale: Opening packages away, restarting after contamination, applying gloves correctly, and recognizing below-waist contamination are correct. The 1-inch border is non-sterile and should not be touched.
The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
- A. Implement visitor restrictions for affected clients
- B. Log entry and exit of all healthcare workers who provide care
- C. Ensure that bleach disinfectant wipes are available in each room
- D. Provide reusable personal protective equipment
- E. Have an observer for donning and doffing of personal protective equipment
Correct Answer: A,B,E
Rationale: Visitor restrictions, logging healthcare worker movements, and an observer for PPE donning/doffing are critical for EVD control. Bleach wipes are insufficient, and reusable PPE is not recommended.
Item 1 of 1
• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The nurse recognizes which of the following treatments are alternative treatments for anxiety. Select all that apply.
- A. Black cohosh
- B. Ginger
- C. St. John's wort
- D. Kava
- E. Passion flower
Correct Answer: D,E
Rationale: Kava and passion flower are used for anxiety relief. Black cohosh treats menopausal symptoms, ginger aids nausea, and St. John’s wort is for depression.