Nokea
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.
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The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client. When administering the IV potassium chloride, which action should the nurse take?
- A. Inject it as a bolus.
- B. Use a filter in the IV line.
- C. Dilute it per medication instructions.
- D. Apply cool compresses to the IV site.
Correct Answer: C
Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein.
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply.
- A. Dyspnea
- B. Cyanosis
- C. Tachypnea
- D. Kussmaul's respiration
- E. Irregular respiratory pattern
- F. Adventitious bubbling lung sounds
Correct Answer: A,B,E,F
Rationale: Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing.
The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information should the nurse share with the client about the therapy?
- A. After the initial dose, subsequent treatments must continue lifelong.
- B. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose.
- C. It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease.
- D. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.
Correct Answer: C
Rationale: Graves' disease is also known as toxic diffuse goiter and is characterized by a hyperthyroid state resulting from hypersecretion of thyroid hormones. After treatment with radioactive iodine therapy, a decrease in the thyroid hormone level should be noted, which helps alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. Occasionally, a client may require a second or third dose, but treatments are not lifelong. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse must reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates.