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When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
- A. 0.5 to 1 inch.
- B. 1 to 1.5 inches.
- C. 1.5 to 2 inches.
- D. 2 to 2.5 inches.
Correct Answer: C
Rationale: Depressing the sternum 1.5 to 2 inches ensures adequate compression depth for effective CPR in adults, per guidelines.
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Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
- A. Elevated red blood cell count.
- B. Decreased platelet count.
- C. Elevated white blood cell count.
- D. Elevated serum blood urea nitrogen concentration.
Correct Answer: C
Rationale: Diverticulitis, an inflammatory condition, typically causes an elevated white blood cell count due to infection or inflammation. Red blood cell count, platelet count, and blood urea nitrogen are not directly affected. CN: Physiological adaptation; CL: Analyze
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:
- A. Put all four side rails up on the bed.
- B. Ask the unlicensed personnel to place restraints on the client's upper extremities.
- C. Request that the client's roommate put the call light on when the client is attempting to get out of bed.
- D. Check on the client at regular intervals to ascertain the need to use the bathroom.
Correct Answer: D
Rationale: Regular checks ensure safety and assist with bathroom needs, addressing dizziness and confusion. Side rails and restraints risk injury or agitation. Relying on a roommate is unreliable.
A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:
- A. Perform arm circles while riding in the car
- B. Perform ankle pumps and foot range-of-motion exercises
- C. Elevate her legs while riding in the car
- D. Take an ambulance home
Correct Answer: B
Rationale: Ankle pumps and foot range-of-motion exercises during the car ride promote venous return, preventing stasis and recurrent thrombophlebitis. Arm circles are irrelevant, elevating legs is impractical, and an ambulance is unnecessary for a discharged client.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included:
- A. Chickenpox.
- B. Poliomyelitis.
- C. Rheumatic fever.
- D. Meningitis.
Correct Answer: C
Rationale: Rheumatic fever in childhood is a common cause of mitral valve disease, leading to stenosis or regurgitation later in life.