UWorld NCLEX-RN QBank 2018
The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis
1, 4 Explanation: Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection.
The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply. 1. "I can apply Vaseline to my nose when my nostrils feel dry from the oxygen." 2. "I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." 3. "I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." 4. "I should not polish my nails when using my oxygen." 5. "I should not use a wool blanket on my bed."
1,2,3 Explanation: Oxygen is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. 1.Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead. 2.Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. 3.The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. (Option 4) The client understands that nail polish remover and nail polish contain acetone, which is highly combustible. (Option 5) Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics.
Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight
1,2,4,6 Explanation: Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: 1. Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. 2. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis 3. Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) 4. Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance 5. Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. (Option 3) Anorexia nervosa manifests as cold intolerance. (Option 5) Anorexia nervosa manifests as lengthy and vigorous exercise.
The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? 1. Call the answering service and speak to the health care provider now 2. Document the results of the culture in the client's medical record 3. Leave a message on the health care provider's office phone 4. Speak to the health care provider on rounds in the morning
1. Call the answering service and speak to the health care provider now Explanation: Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1). (Option 2) The critical laboratory result should be documented in the client's medical record, but only after immediate communication with the HCP. (Option 3) The nurse must make direct contact, either via telephone or in person, when reporting a critical result. A telephone message may not be received promptly, and a critical value requires immediate intervention. (Option 4) Even if the HCP usually makes rounds early in the morning, a critical value requires immediate, real-time notification to prevent delay of potentially urgent intervention.
The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Knee pain 4. Skin peeling
1. Fever Explanation: Kawasaki disease (KD) is a systemic vasculitis of childhood that presents with ≥5 days of fever, nonexudative conjunctivitis, lymphadenopathy, mucositis, hand and foot swelling, and a rash. First-line treatment consists of IV immunoglobulin and aspirin to prevent coronary artery aneurysms. When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health care provider should be notified as this may indicate the acute phase of KD recurrence. The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions. (Option 2) Irritability is a hallmark finding in a child with KD, especially during the acute phase (due to fever and inflammation). Parents should be advised that irritability can last up to 2 months. (Option 3) Temporary joint pain and other manifestations of arthritis (eg, stiffness, decreased range of motion) may occur and persist for several weeks. Parents should be informed that range of motion exercises and warm baths will help reduce these symptoms and minimize discomfort. (Option 4) Desquamation (skin peeling) of the hands and feet is an expected finding in KD. Parents should be informed that the peeling itself is not painful but that the new skin underneath may be red and sore.
The health care provider (HCP) prescribes a 10-day course of amoxicillin for a 1-year-old diagnosed with acute otitis media (AOM). Which instruction is most important for the nurse to review with the child's parents? 1. Return to the office if the child does not improve within 48-72 hours 2. Stop the antibiotic if the child develops diarrhea 3. Stop the antibiotic if the child feels better after 72 hours 4. Use over-the-counter decongestants to help with recovery
1. Return to the office if the child does not improve within 48-72 hours Explanation: AOM is an infection of the middle ear. Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms. Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment. (Option 2) Diarrhea is a frequent side effect of amoxicillin therapy that does not warrant treatment discontinuation. If the client develops fever and abdominal pain associated with diarrhea, it may indicate Clostridium difficile superinfection; this should be reported to the HCP. The medication is stopped immediately if the child develops an allergic reaction (eg, rash, shortness of breath, throat tightness). (Option 3) Ear pain and fever often subside within the first few days of antibiotic treatment. However, the entire course should be completed as prescribed to treat the infection completely and prevent antibiotic resistance. (Option 4) Over-the-counter decongestants are ineffective for AOM treatment and may even delay the recovery process.
The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake 2. Provide frequent rest periods 3. Teach the client to get up slowly form the bed or a sitting position 4. Tell the client to wear sunglasses when outdoors
3. Teach the client to get up slowly form the bed or a sitting position Explanation: Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position. (Options 1, 2, and 4) These are important instructions but not priority ones.
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? EXHIBIT: 1700 Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor.__________RN 1710 Health care provider (HCP) notified of fall. Prescribed CT of head STAT.___________RN 1740 No change in neurologic status. Client to CT via gurney. Report filed per policy.__________RN 1810 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor.__________RN
1740 Explanation: All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record.
While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. 1. Advance the entire stylet into the vein upon venipuncture 2. Insert the IV line into the most distal site of the right arm 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy 5. Teach the client to keep the left arm in a dependent position
2,3,4 Explanation: A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4). In general, venipuncture is contraindicated in upper extremities affected by: •Weakness •Paralysis •Infection •Arteriovenous fistula or graft (used for hemodialysis) •Impaired lymphatic drainage (prior mastectomy) (Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage.
An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple
2,3,5 Explanation: A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: •Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). •Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. •Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). •These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). •Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. •Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth.
The nurse is helping to admit a client with malnutrition related to anorexia nervosa. Which actions are appropriate in the care of this client? Select all that apply. 1. Allow the client to continue to exercise per usual routine 2. Assist the client in reflection on triggers of disordered eating 3. Determine the client's required daily intake of calories 4. Encourage the client to keep a log of foods consumed 5. Monitor the client's weight at the same time each day
2,3,5 Explanation: Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients with anorexia exhibit preoccupation with body image and obsessive behaviors to lose weight (ie, excessive exercising/dieting). Clients commonly have protein-energy malnutrition and may be extremely underweight. Acute care focuses on restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: •Determining minimum caloric intake for healthy weight gain and documentation of consumed calories and protein (Option 3) •Establishing a weekly weight-gain goal - an appropriate goal for most clients is 2-3 lb/wk (0.91-1.36 kg/wk) •Limiting physical activity initially and gradually increasing as oral intake improves •Allowing client to make food choices, when possible, to give a sense of control •Providing reflection with the client about behaviors, triggers, or situations that cause dysfunctional eating (Option 2) •Weighing the client at the same time each day, after voiding, and wearing the same clothing to assess efficacy of nutritional support (Option 5) (Option 1) Allowing the client with anorexia to continue exercising will cause further energy deficit, which can contribute to worsening malnutrition and end-organ damage (eg, renal failure). (Option 4) Extensive focus on food intake (eg, food logs) should be avoided as it may increase the client's preoccupation with eating.
The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP). The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? 1. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today 2. A 6-month-old who had diaphragmatic hernia repair 5 days ago 3. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm3 4. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing
2. A 6-month-old who had diaphragmatic hernia repair 5 days ago Explanation: The LPN should be assigned stable clients with expected outcomes. A 5-day post-diaphragmatic hernia client is stable at this time. The LPN cannot perform initial teaching, assessments, or evaluate a client condition (Option 2). (Option 1) This client is scheduled for surgery today and will require education and evaluation. (Option 3) This client is newly admitted to the unit and will need to be assessed by an RN. (Option 4) This client is not stable. The client is exhibiting signs of diabetic ketoacidosis and will require care provided by an RN.
The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects? 1. Calcium-rich snacks 2. Fortified cereals 3. Organ meats 4. Wild salmon
2. Fortified cereals Explanation: Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily. Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (Option 2). Inadequate maternal intake of folic acid during the critical first 8 weeks after conception (often before a woman knows she is pregnant) increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord. Common NTDs are spina bifida and anencephaly (lack of cerebral hemispheres and overlying skull). (Option 1) Adequate calcium intake is especially important during the last trimester for mineralization of fetal bones and teeth, but it does not prevent NTDs. (Option 3) Organ meats (eg, liver) may contain moderately high levels of folate but are consumed more for their high iron content, which can promote red blood cell formation and prevent maternal anemia. (Option 4) A prenatal diet rich in omega-3 fatty acids is important for fetal neurologic function and is linked to a lower risk of preterm birth. Dietary sources include wild salmon, anchovies, flaxseed, and walnuts.
The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? 1. Imbalanced nutrition 2. Impaired gas exchange 3. Impaired tissue integrity 4. Risk for infection
2. Impaired gas exchange Explanation: ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option 1) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 3) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 4) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND.
The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1-day post tubal myringotomy client with purulent tympanic drainage 2. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae 3. A10-day-old client with a patent ductus arteriosus who has a continuous murmur 4. A 6-year-old client with epiglottitis who is drooling and has a sever sore throat
4. A 6-year-old client with epiglottitis who is drooling and has a sever sore throat Explanation: Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenzae type b (Hib) was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress (Option 4). (Option 1) Purulent drainage is expected in a 1-day post tubal myringotomy client. The drainage shows the procedure was successful. (Option 2) A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client would need to be seen second, as this is a circulation disorder. (Option 3) A murmur is expected in a client with a patent ductus arteriosus. It is best heard at the left infraclavicular area and has a continuous "machinery" quality.
Which of these clients should the nurse assess first? 1. A client who has shortness of breath from moderate pleural effusion and is waiting for thoracentesis 2. A client who just had a long leg cast applied and has severe pain despite a dose of morphine 3. A client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness 4. A sickle cell crisis client who has sever bone pain despite a dose of morphine
3. A client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness Explanation: First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. A client receiving the first dose of an antibiotic is at risk for allergic reactions, including anaphylaxis. Signs and symptoms of anaphylaxis include itching, flushing, hives, wheezing, bronchospasm, swelling of the oral mucosa, and hypotension. This is a potentially fatal complication that requires immediate intervention (Option 3). (Option 1) This client with a moderate pleural effusion awaiting the corrective procedure would be the last client to be assessed by the nurse. Shortness of breath is an expected symptom of pleural effusion. If signs or symptoms of respiratory distress or hypoxemia occur, this client will increase in priority. (Option 2) This client with a new cast experiencing severe pain would be the second client to be assessed. This client is at risk for compartment syndrome and limb loss. Increasing fluid (eg, bleeding) in a confined space or decreasing compartmental capacity (eg, casting) causes neurovascular compromise as the vessels are compressed and unable to deliver oxygen to the tissues. Long bone fractures account for most cases of acute compartment syndrome. (Option 4) This client with sickle cell pain would be evaluated third. Although in crisis, the client is not at risk for loss of life or limb.
A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take? 1. Adenosine is contraindicated for SVT. Verify the order with the health care provider 2. Administer medication only through a central venous access 3. Administer medication rapidly over 1-2 seconds followed by a saline flush 4. Mix medication in 50 mL normal saline and administer over 10 minutes
3. Administer medication rapidly over 1-2 seconds followed by a saline flush Explanation: Adenosine is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid rhythm exceeding 150/min). The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. The injection site should be as close to the heart as possible (eg, antecubital area). The client's ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration. (Option 1) Adenosine is the first-line drug for paroxysmal SVT. (Option 2) Although the drug should be administered as close to the heart as possible, central venous access is not required. (Option 4) Because of the drug's short half-life (5-10 seconds), it should be administered rapidly, not slowly, and should not be diluted.
To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? 1. Angle of Louis at 2nd intercostal space (ICS) to left of sternal border 2. Aortic area at 2nd ICS to right of sternal border 3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter 4. 5th ICS at mid clavicular line (MCL)
3. Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter Explanation: To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. (Option 1) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location is useful in counting the ICSs and in finding auscultatory areas. (Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL.
The nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective? 1. Episodes of spasmodic coughing have decreased. 2. No wheezes are audible on chest auscultation 3. Oxygen saturation has increased from 88% to 93% 4. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min
3. Oxygen saturation has increased from 88% to 93% Explanation: Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. (Option 1) Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. (Option 2) The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. (Option 4) Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected.
A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? EXHIBIT: Laboratory results PH 7.25 PO2 79 mm Hg (10.5 kPa) PaCO2 35 mm Hg (4.66 kPa) HCO3- 12 mEq/L (12 mmol/L) 1. Decrease in bicarbonate reabsorption 2. Decrease in respiratory rate 3. Increase in bicarbonate reabsorption 4. Increase in respiratory rate
4. Increase in respiratory rate Explanation: The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH).
