Critical Thinking
A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a) a chest X-ray. b) monitoring of arterial oxygen saturation (SaO2). c) chest auscultation. d) arterial blood gas (ABG) studies.
A. a chest X-ray Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.
A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: a) neuroleptic malignant syndrome. b) malignant hyperthermia. c) the flu. d) septicemia.
A. neuroleptic malignant syndrome. Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? a) The client with a history of cardioversion for sustained ventricular tachycardia 2 days ago b) The client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday c) The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block d) The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet
C. The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post procedure.
The nurse is preparing to administer 0.1 mg of digoxin intravenously. Digoxin comes in a concentration of 0.5 mg/2 ml. How many milliliters should the nurse administer? ________ ml
0.4 The nurse should administer 0.4 ml to administer 0.1 mg of digoxin I.V. if it comes in a concentration of 0.5 mg/2 ml, or 0.25 mg/ml.
The nurse is to administer midazolam 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer how much? (Fill in the blank with a number.) _______ mL
0.5 Multiply 2.5 mg/5 mg by the unknown X mg/1 mL. Cross-multiply to get 5X = 2.5 mL. Divide both sides of the equation by 5 to get X = 0.5 mL.
During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? a) Maternal hypotension b) Maternal tachycardia c) Fetal tachycardia d) Maternal oliguria
A. Maternal hypotension As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, and fetal and maternal bradycardia (not tachycardia). Although the client may experience some postpartum urine retention, maternal oliguria isn't associated with epidural anesthesia
A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? a) Obtain an order for furosemide 80 mg IV push. b) Arrange for an emergency hemodialysis session. c) Increase the rate of the client's IV fluid to 150 ml/hour. d) Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes.
D. Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes. All the actions listed will reduce the serum magnesium concentration. The calcium gluconate will react the quickest to reduce the critical level.
An outpatient client who has a history of schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which of the following factors should the nurse incorporate into the plan of care when explaining the tactile hallucinations? a) Alcohol withdrawal. b) Ineffectiveness of risperidone. c) Alcohol intoxication. d) Interaction of alcohol and risperidone.
A. Alcohol withdrawal. Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and risperidone have an additive effect, not one of causing hallucinations.
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: a) Cannot speak due to airway obstruction. b) Is coughing vigorously. c) Can make only minimal vocal noises. d) Starts to become cyanotic.
A. Cannot speak due to airway obstruction. The Heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only be initiated when the victim cannot speak.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? a) Control the pain and support breathing and oxygenation. b) Monitor and manage potential complications. c) Decrease the anxiety and reduce the workload on the heart. d) Reduce the nausea and vomiting and stabilize the blood glucose.
A. Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
Which set of postural vital signs (BP and heart rate) indicates inadequate blood volume? a) Supine 120/70, 70 Sitting 102/64, 86 Standing 100/60, 92 b) Supine 124/76, 88 Sitting 124/74, 92 Standing 122/74, 92 c) Supine 138/86, 74 Sitting 136/84, 80 Standing 134/82, 82 d) Supine 100/70, 72 Sitting 100/68, 74 Standing 98/68, 80
A. Supine 120/70, 70 Sitting 102/64, 86 Standing 100/60, 92 There was a significant change in both blood pressure and heart rate with position change. This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20 beats per minute, a possible slight decrease of < 5 mm Hg in the systolic blood pressure, and a possible slight increase of < 5 mm Hg in the diastolic blood pressure.
A nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor? a) The client has a child with cystic fibrosis. b) The client has a history of preterm labor at 32 weeks' gestation. c) The client is 25 years old. d) The client was exposed to rubella at 36 weeks' gestation.
A. The client has a child with cystic fibrosis. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects
A client with type 1 diabetes has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? a) "Insulin requirements usually decrease during the last two trimesters." b) "Insulin requirements usually decrease during the first trimester." c) "Insulin requirements increase greatly during labor." d) "Insulin requirements don't change during pregnancy. Continue your current regimen."
B. "Insulin requirements usually decrease during the first trimester." Maternal insulin requirements usually decrease during the first trimester from rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish from extreme maternal energy expenditure.
A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a) Slurred speech b) Alteration in level of consciousness (LOC) c) Bradycardia d) Decreased heart rate
B. Alteration in level of consciousness (LOC) The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which of the following? a) Small-for-gestational-age fetus. b) Effects of analgesic medication. c) Fetal malposition. d) Maternal fatigue.
B. Effects of analgesic medication Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhythmias. Maternal fatigue, fetal malposition, and small-for-gestational-age fetus are not commonly associated with decreased variability.
A client is receiving fluid replacement with lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 97.2 (36.2° C); heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 ml for the last 2 hours. The IV rate is currently at 375 ml/hr. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: a) Dextrose 5%. b) IV rate increase. c) Fresh frozen plasma. d) Furosemide.
B. IV rate increase. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.
A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? a) Insert an indwelling catheter. b) Massage the fundus. c) Call the physician. d) Pack the vagina with sterile gauze.
B. Massage the fundus. Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which cannot occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus. The priority measure to correct postpartum hemorrhage is to massage the fundus. Packing the uterus with sterile gauze is contraindicated. The physician will have to be called but the nurse must first intervene.
After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? a) Increased heart rate b) Respiratory depression c) Numbness and tingling of the extremities d) Heightened alertness
B. Respiratory depression Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.
When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? a) Heart failure. b) Impaired hearing. c) Prescription drug intoxication. d) Cancer of any kind.
C. Prescription drug intoxication. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) Hyperventilation b) Semiconsciousness c) Delirium d) Hypoxia
D. Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
