10/23 RN Med-Surg

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (SATA) a. tracheal deviation to the left b. temperature of 38.8C (102 F) c. absent breath sounds on the right side d. neck vein distention e. bradypnea

A, C, D A tension pneumothorax can occur following a thoracentesis. A trachea is deviated to the unaffected side instead of being in the center of the neck is a manifestation of pneumothorax. Absent breath sounds on the affected side and neck distention are also manifestations of pneumothorax. As the client's difficulty of breathing increases, the blood flow return compresses, causing the neck veins to distend.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results shold the nurse anticipate as the cause of this ECG change? a. potassium 2.8 mEq/L b. digoxin level 0.7 ng/mL c. hemoglobin 9.8 g/dL d. calcium 8.0 mg

A. Potassium 2.8 mEq/L A flattened T wave or the development of U waves is indicative of a low potassium.

A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? a. WBC 6,000/mm^3 b. potassium 3.0 mEq/L c. clear, pale yellow drainage d. report or abdominal fullness

B. potassium 3.0 mEq/L A potassium level of 3.0 mEq/L is below the expected reference range and can cause dysrhythmias. Dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia.

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS? a. sensory dysfunction b. weakness of the distal extremities c. decreased vision d. altered temperature regulation

B. weakness of the distal extremities ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet, speech, swallowing and breathing

A nurse is preparing a client for d/c who is postoperative following a conventional lumbar disk excision. Which of the following statements indicates that the client understands the nurse's instructions? a. I should have no problem climbing stairs when I get home b. I'll wait about 3 weeks before I return to my usual activities c. I'll use my heating pad if I feel any muscle spasms in my back d. I can go back to driving in about 2 weeks

C. I'll use my heating pad if I feel any muscle spasms in my back The client should apply heat to the back to relax the paraspinal muscles and reduce spasms

A nurse in the emergency department is caring for a client who reports pain in her left leg following a MVA. The client's left leg has bruising, swelling and displacement of the bones. Which of the following actions should the nurse take first? a. obtain an XR of the injured leg b. apply ice packs to the affected area c. check neurovascular status distal to the injury d. elevate the affected leg on 2 pillows

C. check neurovascular status distal to the injury The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy or needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is impaired circulation to the limb from trauma and the resulting edema; therefore, the first action is to check the circulation, sensation and movement distal to the level of the injury. If the nurse notes a weak of absent pulse distal to the injury, the limb's circulation is compromised, and immediate action is critical.

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? a. high-pitched sound heard in the ear b. intermittent rapid eye movement c. itching of the external canal d. feeling of fullness in the ear

D. feeling of fullness in the ear A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? a. hypokalemia b. lead poisioning c. hypercalcemia d. iron toxicity

D. iron toxicity A client who has received several blood transfusions. is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.

A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the following directions should the nurse provide? a. you should fast for 8 hours after the PSA test b. annual PSA screening should begin at age 40 c. expected PSA values will decrease as you get older d. you should not ejaculate for 24 hours prior to the PSA test

D. you should not ejaculate for 24 hours prior to the PSA test PSA is a glycoprotein manufactured in their prostate that is used to screen for prostate cancer. Ejaculation within 24 hours prior to the test can falsely elevate levels of PSA

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis? a. reticulocyte count b. rheumatoid factor c. direct coombs' test d. platelet count

b. rheumatiod factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.