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Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.
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A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
- A. A hemolytic reaction to mismatched blood
- B. A hemolytic reaction to Rh-incompatible blood
- C. A hemolytic allergic reaction caused by bacterial contamination of donor blood
- D. None of the above
Correct Answer: A
Rationale: The client is likely experiencing a hemolytic reaction to mismatched blood due to the symptoms of chills, dyspnea, and urticaria occurring shortly after beginning the blood transfusion. These symptoms are classic signs of a transfusion reaction, especially a hemolytic reaction where the recipient's immune system attacks the transfused red blood cells. This can happen if the donor blood is not compatible with the recipient's blood type, leading to a severe reaction. It is crucial to report this immediately to the physician to halt the transfusion and provide appropriate treatment to the client.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: A client with the syndrome of inappropriate antidiuretic hormone (SIADH) retains water excessively due to overproduction of antidiuretic hormone (ADH). This leads to dilutional hyponatremia, resulting in decreased serum sodium levels. Hyponatremia is a hallmark laboratory finding in patients with SIADH. Other laboratory values you might see in SIADH include decreased serum osmolality, concentrated urine with a high sodium concentration, and normal renal function tests such as BUN and creatinine. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level.
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
The bronchospasm and dyspnea are clinical manifestation of organophosphorus poisoning are caused by :
- A. muscarinic action
- B. nicotinic action
- C. CNS action
- D. all the above
Correct Answer: A
Rationale: The bronchospasm and dyspnea seen in organophosphorus poisoning are primarily caused by the muscarinic action of the toxic substance. Organophosphates inhibit acetylcholinesterase, leading to an excess of acetylcholine at the neuromuscular junctions. This results in overstimulation of muscarinic receptors, causing symptoms such as bronchoconstriction, increased secretions, and respiratory distress. Nicotinic actions primarily lead to muscle weakness and paralysis, while CNS actions can cause seizures and altered mental status. So, in the case of bronchospasm and dyspnea, the muscarinic action is the main contributing factor.