Nokea
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
- A. Increased anteroposterior chest diameter.
- B. Underdeveloped neck muscles.
- C. Collapsed neck veins.
- D. Increased chest excursions with respiration.
Correct Answer: A
Rationale: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.
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An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.
The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply.
- A. It should be administered in the anterior area of the iliac crest.
- B. The onset is immediate.
- C. Use a 27G, 5/8€ needle.
- D. Cephalosporin potentiates the effects of heparin.
- E. Double check the dose with another nurse.
Correct Answer: C,E
Rationale: Subcutaneous heparin should be administered using a 27-gauge, 5/8-inch needle to ensure proper delivery into subcutaneous tissue. Due to the risk of bleeding, the dose should be double-checked with another nurse. The anterior iliac crest is not a standard site (abdomen is preferred), onset is not immediate (takes hours), and cephalosporins do not potentiate heparin's effects.
The nurse is preparing to administer prescribed medications to a client via a nasogastric tube connected to low-intermittent suction. The nurse should take which appropriate action? Select all that apply.
- A. Position the client in Trendelenburg position.
- B. Verify correct placement of the tube before medication administration.
- C. Turn off the suction during medication administration.
- D. Resume low-intermittent wall suction immediately after medication administration.
- E. Irrigate the nasogastric tube (NGT) with sterile water.
Correct Answer: B,C
Rationale: Verifying tube placement and turning off suction ensure safe medication administration; Trendelenburg is inappropriate, and sterile water is not required.
A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply.
- A. Images will appear to be one-third larger.
- B. Look through the center of the glasses.
- C. Use handrails when climbing stairs.
- D. Stay out of the sun for 2 weeks.
Correct Answer: A,B,C
Rationale: The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Staying out of the sun is not necessary, but dark glasses may be used to prevent photophobia.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
- A. Review the results of culture and sensitivity testing of the wound.
- B. Look for the presence of a pressure dressing over the wound.
- C. Determine if the client has increased pain from exposed nerve endings.
- D. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.