Nokea
When assessing a client with acute asthma, the nurse is most likely to obtain which finding?
- A. Pursed lip breathing and clubbing of fingers
- B. Fever and a high-pitched inspiratory stridor
- C. A short expiratory phase and hemoptysis
- D. Cough and musical breath sounds on expiration
Correct Answer: D
Rationale: When assessing a client with acute asthma, a cough and wheezing or musical breath sounds on expiration are typical findings. Pursed lip breathing and clubbing of fingers (choice A) are not common in acute asthma but could be seen in chronic respiratory conditions. Fever and high-pitched inspiratory stridor (choice B) are more indicative of croup or epiglottitis. A short expiratory phase and hemoptysis (choice C) are not typical findings in acute asthma.
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When should the nurse conduct an Allen's test?
- A. When obtaining pulmonary artery pressures
- B. To assess for the presence of a deep vein thrombus in the leg
- C. Just before arterial blood gases are drawn peripherally
- D. Prior to attempting a cardiac output calculation
Correct Answer: C
Rationale: The correct time to conduct an Allen's test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen's test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen's test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen's test is not done specifically before attempting a cardiac output calculation.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct Answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.
The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
- A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
- B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills
Correct Answer: C
Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.
A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?
- A. Increase the intake of salty foods
- B. Administer NaCl supplements
- C. Restrict oral fluid intake
- D. Hold the client's loop diuretic
Correct Answer: C
Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.
Which client's vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?
- A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
- B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
- C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
- D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.
Correct Answer: C
Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.