1200: Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion noted. Neck veins flat. No peripheral edema observed.
Blood pressure 136/90 mm Hg
Respiratory rate 32/min
Temperature 38.7° C (101.6° F)
Heart rate 110/min
SaO2 90% on 3 L/min via nasal cannula
The client is most likely experiencing _________ and__________.
A. Pnuemonia
B. Pneumothorax
C. Fluid Volume Overload
D. Acute Chest Syndrome | Answer: The client is most likely experiencing PNEUMONIA
and ACUTE CHEST SYNDROME
D - The client is most likely experiencing acute chest syndrome, which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain.
A - The client is most likely experiencing pneumonia as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain.
Rationale:
C - While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein distension, and hypertension.
B - While the client is experiencing increased respiratory distress, a pneumothorax typically presents with reduced or absent breath sounds and unequal chest expansion. |
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?
A. Wear a mask.
B. Wear a gown.
C. Keep the client's room well-lit.
D. Maintain the head of the bed at a 45° elevation. | Answer: A. Wear a mask
- Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.
Rationale:
B - A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis does not spread via direct contact.
C - Staff caring for this client should keep the illumination in the room dim and avoid bright light from windows to promote comfort and rest and avoid photophobia.
D - Staff caring for this client should keep the head of the bed at a 30° elevation |
A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching?
A. "I will avoid eating raw fruits and vegetables."
B. "I can ask a friend to change my cats litter box."
C. "I will use a mild soap when washing my genital area."
D. "I can sip on a glass of juice for at least 2 hours before I should discard it." | Answer: B. "I can ask a friend to change my cats litter box."
- Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's litter box.
Rationale:
A - The nurse should instruct the client to wash raw fruits and vegetables thoroughly prior to eating them, because uncleaned fruits and vegetables can contain micro-organisms and place the client at risk for an infection.
C - The nurse should instruct the client to wash genital area twice a day with anti-microbial soap to prevent bacterial and fungal infections.
D - The nurse should instruct the client to avoid drinking any liquids that have been out for more than 1 hr. Beverages left out for extended periods of time could expose the client to micro-organisms and place them at risk for an infection. |
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?
A.Restlessness
B. T3 level 215 ng/dL (40 to 180 ng/dL)
C. Blood pressure 170/80 mm Hg
D. Decreased weight | Answer: C. Blood pressure 170/80 mm Hg
- Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.
Rationale:
A - Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.
B - An elevated T3 level is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.
D - Decreased weight is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. |
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?
A. Bounding pedal pulse
B. Capillary refill less than 2 seconds
C. Pain that increases with passive movement
D. Areas of warmth on the cast | Answer: C. Pain that increases with passive movement
- The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.
Rationale:
A - The nurse should expect a client who has compartment syndrome to have a diminished pulse or pulselessness in the affected extremity due to lack of distal perfusion caused by a decrease in the muscle compartment size.
B - The nurse should expect a client who has compartment syndrome to have capillary refill greater than 2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a decrease in the muscle compartment size.
D - A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an infection of the underlying tissue, not compartment syndrome. |
Client presents with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7/ 10. Client also reports N/V and dyspepsia. Client is A&O x3. Lung sounds clear B/L S1 and S2.
Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)
ALT 39 international units/L (4 to 36 international units/L)
LDH 200 units/L (100 to 190 units/L) WBC count 12,000/mm3 (5,000 to 10,000/mm3)
Potential Conditions: - Cholecystitis - Appendicitis - Ulcerative colitis
- Peritonitis Actions to Take: - Maintain the client in semi-Fowler's position. - Administer morphine IV. - Place the client on bed rest.
- Ensure the client is NPO. - Insert an NG tube.
Parameters to Monitor: - Monitor the client for rectal bleeding.
- Monitor the color of the client's stools. - Monitor for pain at McBurney's point. - Monitor the client for a rigid, board-like abdomen. - Monitor the client for dark urine. | Answer: The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine. |
A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?
A. Oral Candidiasis (Thrush)
B. Dry Oral Mucous Membrane/Tongue with Deep Furrows
C. Glossitis
D. Healthy tongue | Answer: C. Glossitis
- This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.
Rationale:
A - This image depicts oral candidiasis, or thrush, which is an overgrowth of yeast (Candida albicans) in the mouth, which results in a yellowish-white coating on the surface of the tongue.
B - This image depicts a dry oral mucous membrane and tongue, with deep furrows on the surface of the tongue that indicate dehydration.
D - This image depicts a healthy tongue that is dull red in color and moist with a slightly rough anterior surface. |
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?
A. Try to walk at least three times per week for exercise.
B. To increase stamina, walk for 5 min after fatigue begins.
C. Take over-the-counter cough medicine for persistent cough.
D. Use a salt substitute to reduce sodium intake. | Answer: A. Try to walk at least three times per week for exercise.
- The development of a regular exercise routine can improve outcomes in clients who have heart failure.
Rationale:
B - Walking for 5 min after the onset of fatigue will not increase stamina and can exacerbate the client's heart failure.
C - The provider should approve the use of over-the-counter cough medication for a persistent cough prior to use. A persistent cough can exacerbate the client's heart failure.
D - Salt substitutes contain an increased amount of potassium, which can place the client at an increased risk for hyperkalemia. |
A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?
A. Painless ulcerations on the ankles
B. Hair loss on the lower legs
C. No extremity pain when resting
D. Rubor with elevation of the extremity | Answer: B. Hair loss on the lower legs
- The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.
Rationale:
A - The nurse should expect a client who has peripheral arterial disease to have painful ulcerations on the ends of toes and between the toes as a result of impaired arterial circulation.
C - The nurse should expect a client who has peripheral arterial disease to have pain when resting as a result of the outflow of the blood in the lower extremities when at rest. This pain is relieved by dangling the lower extremities off a bed.
D - The nurse should expect a client who has peripheral arterial disease to have dependent rubor, which is redness as a result of dangling or ambulation. |
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?
A. Encourage the client to eat raw fruits and vegetables.
B. Avoid placing plants or flowers in the client's room.
C. Limit visitors to members of the client's immediate family.
D. Wear an N95 respirator mask when providing care to the client. | Answer: B. Avoid placing plants or flowers in the client's room.
- Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.
Rationale:
A - The nurse should identify that P. aeruginosa can be found in raw fruits and vegetables.
C - The nurse does not need to limit visits to family members. However, the nurse should prohibit visits from those at risk for P. aeruginosa infection, such as anyone who is ill, other hospitalized clients, and small children.
D - P. aeruginosa spreads by contact, either on health care workers' hands or contaminated equipment. It is not airborne, so respirator masks are unnecessary. |
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?
A. "It is just easier to let my partner administer my insulin."
B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror."
C. "I'm concerned I won't be able to read my blood sugar level because the screen is so small."
D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to." | Answer: B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror."
- This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.
Rationale:
A - This statement does not indicate that the client is successfully coping with the change.
C - This statement does not indicate that the client is successfully coping with the change. The nurse should provide the client with a monitor that has a larger screen.
D - This statement does not indicate that the client is successfully coping with the change. |
A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.
B. Assist the client to start arm exercises 48 hr after surgery.
C. Maintain the right arm in an extended position at the client's side when in bed.
D. Place the client in a supine position for the first 24 hr after surgery. | Answer: A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. - The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
Rationale:
B - The nurse should instruct the client to start exercising the right arm 24 hr after surgery. C - The nurse should elevate the client's right arm on a pillow to promote lymphatic fluid return. D - The nurse should elevate the head of the client's bed to at least 30° to promote drainage from the surgical site and facilitate breathing. |
Cough:
- Client states that sleep during the night is interrupted by coughing and shortness of breath most nights of the week.
Temp: 38.7° C (101.6° F)
Breath Sounds: Wheezes noted bilaterally. Use of accessory muscles noted. Client speaks in short phrases, with report of increased shortness of breath when speaking. Client states that sleep during the night is interrupted by coughing and shortness of breath most nights of the week.
ABG:
- pH 7.30 (7.35 to 7.45)
- PaO2 70 mm Hg (80 to 100 mm Hg)
- PaCO2 47 mm Hg (35 to 45 mm Hg)
- HCO3- 24 mEq/L (21 to 28 mEq/L)
- SaO2 90% on room air (95% to 100%)
RR: 24/min
HR: 104/min
For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process. | Cough (3)
- Emphysema, Asthma, Pneumonia
Temperature (1)
- Pneumonia - Fever is a manifestation of pneumonia and is related to inflammation or infection.
Breath Sounds (3)
- Emphysema, Asthma, Pneumonia
- It is the result of narrowed airways and alveoli.
ABG (2)
- Results indicate Respiratory Acidosis (manifestation) of Emphysema and Pneumonia
RR (3)
- Emphysema, Asthma, Pneumonia
HR (3)
- Client is experiencing Tachycardia which is a manifestation of Emphysema, Asthma, Pneumonia |
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?
A. 240 mL (8 oz) of orange juice
B. 1 ampule of 50% dextrose IV bolus
C. NPH insulin 60 units subcutaneous
D. Regular insulin 20 units IV bolus | Answer: D. Regular insulin 20 units IV bolus
- DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.
Rationale:
A - DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Orange juice would increase the client's blood glucose levels.
B - DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. An ampule of 50% dextrose would increase the client's blood glucose levels.
C - NPH insulin is a long-acting insulin with an onset of 1.5 to 4 hr. The treatment goal for a client who has DKA is to reduce the blood glucose level 50 to 75 mg/dL every hour, which requires the nurse use a faster-acting insulin. |
A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following results is an indication of an adverse effect of the medication?
A. Increased potassium
B. Increased magnesium
C. Increased BUN
D. Increased hematocrit | Answer: C. Increased BUN
- Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.
Rationale:
A - Amphotericin B can cause damage to the kidneys and cause hypokalemia.
B - Amphotericin B can cause several metabolic imbalances, including hyponatremia, hypokalemia, and hypomagnesemia.
D - Amphotericin B can cause bone marrow suppression and, as a result, a decreased hematocrit. |
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
A. Initiate IV therapy with a large-bore catheter
B. Administer oxygen via a nonrebreather mask
C. Insert an NG tube
D. Administer Famotidine | Answer:.
1. Administer oxygen via a nonrebreather mask
2. Initiate IV therapy with a large-bore catheter
3. Insert an NG tube
4. Administer Famotidine
Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer famotidine when the client is no longer bleeding. |
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?
A. Hypotension
B. Tachypnea
C. Nuchal rigidity
D. Bradycardia | Answer: D. Bradycardia
- BradycardiaA client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
Rationale:
A - A client who has increased intracranial pressure from a traumatic brain injury can develop hypertension, which is one component of Cushing's triad.
B - A client who has a traumatic brain injury can develop decreased cerebral blood flow, which results in increased arterial pressure. The changes to arterial pressure cause changes in blood pressure. However, respirations are not affected.
C - Nuchal rigidity, or neck stiffness, is an indication of meningitis. |
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?
A. INR 1 (0.8 to 1.1)
B. INR 2.5 (0.8 to 1.1)
C. aPTT 45 seconds (30 to 40 seconds)
D. aPTT 90 seconds (30 to 40 seconds) | Answer: B. INR 2.5 (0.8 to 1.1)
- Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
Rationale:
A - INR, along with PT, is obtained to measure the clotting abilities of the blood in a client who is taking warfarin. This INR value is below the target reference range for a client who has atrial fibrillation.
C - Clients who are receiving heparin should have aPTT levels monitored to ensure appropriate anticoagulation is achieved. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds.
D -
aPTT is obtained to measure the clotting abilities of the blood. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds. |
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?
A. Document that depolarization has occurred.
B. Increase the pacemaker's voltage.
C. Decrease the pacemaker's sensitivity.
D. Check the placement of the ECG leads. | Answer: A. Document that depolarization has occurred.
- When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.
Rationale:
B - The presence of a QRS complex after the spike indicates that the pacemaker has adequate voltage to stimulate the heart.
C - Sensitivity should be decreased if the pacemaker fires at a regular rate in the presence of an adequate intrinsic rhythm, which is not the case for this client.
D - A pacing stimulus followed by a QRS complex indicates the pacemaker is firing correctly. The ECG leads are detecting this activity and do not need to be checked. |
A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?
A. Change the dressing every 72 hr.
B. Immobilize the hand with a pressure dressing.
C. Take pain medication 30 min after changing the dressing.
D. Wrap fingers with individual dressings. | Answer: D. Wrap fingers with individual dressings
- The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.
Rationale:
A - The nurse should instruct the client to change the dressing every 12 to 24 hr to allow for wound inspection. The client should observe the wound closely for manifestations of increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection.
B - A client who undergoes surgery to receive skin grafts for full-thickness burns should elevate and immobilize the graft site with cotton pressure dressings for 3 to 5 days following the procedure. This action prevents the graft from dislodging and allows for revascularization of the wound.
C - The nurse should instruct the client to take pain medication 30 min before a dressing change to decrease the level of pain during the procedure. |
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?
A. Decreased T cells
B. Increased creatinine clearance
C. Increased eosinophils
D. Decreased viral load | Answer: D. Decreased viral load
- Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.
Rationale:
A - T cells are responsible for cellular immunity. The T cell count indicates the body's ability to fight opportunistic infections and cancer. A decreased T cell count indicates the progression of HIV. Once the T cell count falls below 200 cells/mm3, the client receives a diagnosis of AIDS.
B - Creatinine clearance measures the ability of the kidneys to filter the blood. An increased creatinine clearance level indicates compromised renal function, which is a common occurrence in clients who have HIV.
C - Eosinophils are a type of leukocyte that are responsive to parasitic infections and allergic reactions. An increase in eosinophils indicates the presence of infection. |
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?
A. Heart rate 110/min
B. Blood pressure 160/70 mm Hg
C. Respiratory rate 14/min
D. Temperature 38.4° C (101.1° F) | Answer: A. Heart rate 110/min
- One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.
Rationale:
B - An early sign of hemorrhage is a slight increase in the diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An increase in blood pressure postoperatively can indicate that the client is in pain.
C - An increase in the respiratory rate from the client's baseline is an indication of hemorrhage.
D - An increase in temperature from the client's baseline is an indication of infection, not hemorrhage. |
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
A. Low urine specific gravity
B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia | Answer: A. Low urine specific gravity
- An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
Rationale:
B - The nurse should expect a client who has diabetes insipidus to have hypotension due to dehydration caused by excessive excretion of urine.
C - The nurse should expect a client who has diabetes insipidus to have weak peripheral pulses due to dehydration caused by excessive excretion of urine.
D - Hyperglycemia is a manifestation of diabetes mellitus. Manifestations of diabetes insipidus include polydipsia and polyuria. |
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?
A. The chest tube is draining serosanguineous fluid at 65 mL/hr.
B. The client tolerates gentle milking of the tubing.
C. Bubbling in the water seal chamber has ceased.
D. There is tidaling in the water seal chamber. | Answer: C. Bubbling in the water seal chamber has ceased.
- Bubbling in the water seal chamber ceases when the lung re-expands.
Rationale:
A - Serosanguineous drainage of 65 mL/hr is an expected finding for the client but does not indicate lung re-expansion.
B - The nurse can gently milk the chest tube to release clots, but the client's ability to tolerate this action does not indicate lung re-expansion.
D - The presence of tidaling in the water seal chamber results from the client's inhalation and exhalation and is not indicative of lung re-expansion. |
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take?
A. Inspect the cast for drainage once every 24 hr.
B. Check that one finger fits between the cast and the leg.
C. Perform neurovascular checks every 2 to 3 hr.
D. Make sure the client has a warm blanket covering the cast. | Answer: B. Check that one finger fits between the cast and the leg.
- To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.
Rationale:
A - The nurse should inspect the cast for drainage and alignment at least once every 8 to 12 hr.
C - For the first 24 hr after cast application, the nurse should check the neurovascular status of the client's leg every hour. The nurse does this by assessing sensation, motion, and circulation.
D - The nurse should make sure the cast is uncovered to allow for thorough air drying of the plaster. Also, the heat that is generated by the drying process has to escape. |
A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take?
A. Administer a placebo to the client without their knowledge.
B. Instruct the client on alternative therapies for pain reduction.
C. Tell the client not to worry about addiction to prescribed narcotics.
D. Suggest the client receive a different opioid for pain reduction. | Answer: B. Instruct the client on alternative therapies for pain reduction.
- The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.
Rationale:
A - The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights.
C - This response by the nurse is nontherapeutic because it dismisses the client's concerns.
D - By suggesting the client receive a different opioid for pain reduction, the nurse is disregarding the client's concerns about opioid use disorder. |
A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions?
A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.
B. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy.
C. Family members should follow airborne precautions at home.
D. A follow-up tuberculosis skin test is necessary in 2 months. | Answer: A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.
- After three negative sputum cultures, the client is no longer considered infectious.
Rationale:
B - The client's infection is usually no longer contagious after taking TB medications for 2 to 3 weeks.
C - Family members do not need to follow airborne precautions because they have already been exposed to TB.
D - A follow-up evaluation of the client's TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive. |
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?
A. Use pillows to support the client's head and neck.
B. Offer opioid medication.
C. Place a tracheostomy tray at the bedside.
D. Place the client in semi-Fowler's position. | Answer: C. Place a tracheostomy tray at the bedside.
- The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.
Rationale:
A - The nurse should use pillows to support the client's head and neck to prevent stress on the suture line, but this action is not the priority.
B - The nurses should offer opioid medication for pain relief, but this action is not the priority.
D - The nurse should place the client in semi-Fowler's position to avoid neck extension, but this action is not the priority. |
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial rebreather mask | Answer: A. Nonrebreather mask
- The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.
Rationale:
B - The nurse should initiate a Venturi mask for a client who requires an exact oxygen flow. A Venturi mask can only deliver an oxygen concentration between 24% and 50%.
C - The nurse should initiate a simple face mask for a client who requires short-term supplemental oxygen. A simple face mask can only deliver an oxygen concentration between 40% and 60%. A simple face mask does not usually fit well and can lead to skin breakdown.
D - The nurse should initiate a partial rebreather mask for a client who can sustain adequate oxygen saturation levels with a mixture of room air and oxygen. A partial rebreather allows a portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to a range between 60% and 75%. |
A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching?
A. Drink 240 mL (8 oz) of water after administration.
B. Expect results in 4 to 6 hr.
C. Take this medication before meals to increase appetite.
D. Reduce dietary fiber intake to improve medication absorption. | Answer: A. Drink 240 mL (8 oz) of water after administration.
- The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.
Rationale:
B - The client should expect results in 12 to 24 hr and bowel regularity in 2 to 3 days.
C - The client should take the medication after meals to prevent appetite suppression.
D - Reducing dietary fiber intake does not affect medication absorption. However, the client should increase dietary fiber intake for management of chronic constipation. |