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What should the nurse do first for a client with a suspected spinal cord injury?
- A. Immobilize the spine.
- B. Administer pain medication.
- C. Check motor function.
- D. Obtain a CT scan.
Correct Answer: A
Rationale: Immobilizing the spine is the first priority to prevent further injury in a suspected spinal cord injury.
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When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following?
- A. Occurnt the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale.
- B. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle.
- C. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds.
- D. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.
Correct Answer: C
Rationale: Effective deep breathing post-lobectomy involves relaxing abdominal muscles, taking a slow nasal breath, holding it 3–5 seconds, and exhaling to expand lungs. Contracting muscles or mouth breathing is less effective.
A client undergoing chemotherapy tells the nurse, 'I do not want to get out of bed in the morning because I am so tired.' The nursing plan of care should include:
- A. Education on the use of Neupogen (filgrastim).
- B. Individually tailored exercise program.
- C. Weight lifting when not experiencing fatigue.
- D. Bed rest until chemotherapy is completed.
Correct Answer: B
Rationale: An individually tailored exercise program can help combat fatigue, improve energy levels, and enhance quality of life for chemotherapy patients.
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
- A. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath.
- B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain.
- C. A 35-year-old client with suspected tuberculosis who is complaining of a cough.
- D. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (A). The postoperative client with pain (B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (D) is stable.
When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to:
- A. Ventilate with an oxygenated Ambu bag.
- B. Shock the client with ECG paddles.
- C. Administer 0.5 mL 1:1000 epinephrine.
- D. Titrate flumazenil (Romazicon).
Correct Answer: D
Rationale: Flumazenil is the specific reversal agent for benzodiazepine overdose, such as with midazolam. Titrating flumazenil reverses sedation and respiratory depression effectively.
The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.