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Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
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The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
- A. increase the heart rate
- B. lead to dehydration
- C. are considered aerobic
- D. may be competitive
Correct Answer: B
Rationale: lead to dehydration. The client must take in adequate fluids before and during exercise periods.
The nurse at the prenatal clinic is reinforcing education to a client who is HIV positive. Which information is appropriate for the nurse to include?
- A. Prescribed antiretroviral therapy should be continued during pregnancy
- B. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth
- C. The infant should be exclusively breastfed for 6 months to receive maternal antibodies
- D. The infant will not require treatment for HIV after birth
Correct Answer: A
Rationale: Continuing antiretroviral therapy (A) during pregnancy reduces HIV transmission to the infant. Tdap vaccine (B) is recommended in pregnancy. Breastfeeding (C) is contraindicated in HIV-positive mothers in high-resource settings. Infants (D) require prophylaxis post-birth.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
A client using a diaphragm should be instructed to:
- A. Refrain from keeping the diaphragm in longer than 8 hours.
- B. Keep the diaphragm in a warm location.
- C. Have the diaphragm resized if she gains 5 pounds.
- D. Have the diaphragm resized if she has any surgery.
Correct Answer: A
Rationale: Leaving a diaphragm in place longer than 8 hours increases infection risk. Resizing is needed for significant weight changes (e.g., 10+ pounds) or post-surgery, not minor changes.