Adult Health, Respiratory

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)? 1. Pedal pulses 2+ 2. Tracheal deviation to the left 3. Capillary refill time of 2 seconds 4. Ecchymosis noted on the chest and abdomen

2. Tracheal deviation to the left Rationale: A tension pneumothorax is a life-threatening emergency that results when air enters the pleural space but cannot escape. The intrapleural pressures increasingly elevate, which results in compression of the lung on the affected side and pressure on the heart and great vessels, which decreases cardiac output. The mediastinum also shifts toward the unaffected side, which further compromises oxygenation by compressing the unaffected lung. The trachea deviates towards the unaffected side. Option 2 is an abnormal assessment finding that indicates the client is suffering from a tension pneumothorax and needs to be immediately reported to the registered nurse, who will then notify the primary health care provider. Options 1 and 3 are normal assessment findings. Option 4 is an expected assessment finding for a client who suffered blunt trauma to those areas and is not the priority over option 2.

The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification? 1. "I am urinating a lot." 2. "My pulse is really slow." 3. "I am sweating for no reason." 4. "My blood pressure is really high."

1. "I am urinating a lot." Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? 1. "I can eat foods that contain potassium." 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

1. "I can eat foods that contain potassium." Rationale: A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.

A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information would the nurse reinforce upon discharge? 1. Keep insulin vials refrigerated at all times. 2. Rotate the insulin injection sites systematically. 3. Increase the amount of insulin before unusual exercise. 4. Monitor the urine acetone level to determine the insulin dosage.

2. Rotate the insulin injection sites systematically. Rationale: Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason? Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone.

3. Treat hypocalcemic tetany. Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents? 1. Allow the infant to signal a need. 2. Anticipate all of the needs of the infant. 3. Attend to the crying infant immediately. 4. Avoid the infant during the first 10 minutes of crying.

1. Allow the infant to signal a need. Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect.

The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? 1. Polyuria 2.Shakiness 3.Blurred vision 4.Fruity breath odor

2. Shakiness Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake."

3. "I need to buy special dietetic foods." Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet, but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction would be included in the plan of care? 1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. 3. Apply a moisturizing lotion to dry feet, but not between the toes. 4. Always have a podiatrist cut your toenails; never cut them yourself.

3. Apply a moisturizing lotion to dry feet, but not between the toes. Rationale: The client should use a moisturizing lotion on his or her feet but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone level. 3. Monitor blood glucose level frequently. 4. Receive appropriate follow-up health care.

3. Monitor blood glucose level frequently. Rationale: Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the PHCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my primary health care provider (PHCP) if my blood glucose level is consistently greater than 250."

4. "I will notify my primary health care provider (PHCP) if my blood glucose level is consistently greater than 250." Rationale: During illness, the client should monitor the blood glucose level, and he or she should notify the PHCP if the level is greater than 250. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice.

The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition.

4. Reassure the client that this is usually a temporary condition. Rationale: Weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.