ABC's - ELSEVIER | Comprehensive Review for the NCLEX-PN® Exam, 8e

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the client's room to ensure that which priority item is at the bedside?

A pair of scissors. Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. If the gastric balloon of the tube ruptures, the tube will move upward and potentially occlude the client's airway. The client needs to be observed for sudden respiratory distress. If this occurs, the RN is notified immediately, and the balloon lumens will be cut. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may also be kept at the bedside, but it is not the priority item.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?

Administer oxygen by face mask, as prescribed. Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Monitoring vital signs and elevating the head of the bed may be components of the plan of care, but they are not the most important actions from the options provided. The nurse should not increase the intravenous rate without a prescription from the primary health care provider to do so.

A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery?

Assess patency of the airway. Rationale: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse would take which action first?

Clear and maintain an open airway. Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take?

Encourage the client to slow down breathing. Rationale: The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse would place the client in which position for insertion?

High-Fowler's position. Rationale: Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.

Notify the RN. Discontinue suctioning until the client is stabilized. Rationale: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, which is the priority nursing action?

Notify the registered nurse (RN) immediately. Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse should immediately contact the RN, who then contacts the primary health care provider. Monitoring maternal vital signs and labor progress and encouraging relaxation and breathing techniques will delay necessary and immediate interventions.

Which would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses. Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check which item?

Vital signs. Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the information in the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia.