Complex II Exam 2
A client with urolithiasis is being evaluated to determine the type of urinary calculi that might be excreted. The nurse should plan to keep which item available in the client's room to assist in this process? A. A strainer B. A calorie count sheet C. A vital signs graphic sheet D. An intake and output record
A. A strainer
A client has been diagnosed with acute pyelonephritis. For which manifestation of this disorder should the nurse assess the client? A. Pale, dilute urine B. Low-grade fever C. Chills and nausea D. Flank pain on the unaffected side
C. Chills and nausea
The nurse is assessing the function of a chest tube drainage system attached to a client who had a thoracotomy 1 day ago. Which findings should the nurse expect to note? Select all that apply. A. Drainage of 50 mL/hr B. Pink fluid in the drainage collection chamber C. Excessive bubbling in the water seal chamber D. Gentle bubbling in the suction control chamber E. Fluctuation of fluid in the tube in the water seal chamber F. Chest drainage tubing resting on the bed under the client's legs
A, B, D, E The chest tube drainage system is a device using a one-piece disposable plastic unit with three chambers (drainage, water seal, suction control) that duplicates the three-bottle system. The drainage collection chamber collects drainage from the client's pleural space. An amount of 50 mL/hr is not excessive in a 1-day postoperative client; however, the health care provider is notified if drainage of more than 100 mL/hr occurs. The water seal chamber prevents water from entering the pleural space. Bubbling in this chamber indicates air drainage from the client. Excessive bubbling may indicate an air leak in the system; if this occurs, further intervention is needed to locate the air leak. Fluctuation of fluid in the tube in the water seal chamber is expected and occurs as the client inhales and exhales. Gentle bubbling should be noted in the suction control chamber when suction is applied. The chest drainage tubing should not be kinked or obstructed (e.g., from the client lying on the tube) because this will build pressure in the system, disrupt its functioning, and harm the client.
A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that this client has which type of fracture? A. Simple B. Greenstick C. Compound D. Comminuted
C. Compound
A client has fractured the left radius and has a short arm cast applied. The nurse who is assessing the client for signs/symptoms of compartment syndrome should assess for which finding? A. Aggravation of left arm pain with limb elevation B. Absence of left arm pain with passive movement C. Left arm pain that is relieved by opioid analgesics D. Paralysis of the left hand not preceded by paresthesias
A. Aggravation of left arm pain with limb elevation
A client has had placement of an arm cast to treat a fracture. The nurse assesses the client for signs and symptoms of compartment syndrome and checks for which finding? A. Aggravation of pain with limb elevation B. Pain that is relieved by opioid analgesics C. Absence of pain with passive movement D. Paralysis of the hand not preceded by paresthesias
A. Aggravation of pain with limb elevation
For a male client with an endotracheal (ET) tube, which nursing action is most essential? A. Auscultating the lungs for bilateral breath sounds B. Turning the client from side to side every 2 hours C. Monitoring serial blood gas values every 4 hours D. Providing frequent oral hygiene
A. Auscultating the lungs for bilateral breath sounds
A client with acute glomerulonephritis has had a urinalysis sent to the laboratory. The report reveals that there are hematuria and proteinuria in the urine. How should the nurse interpret these results? A. Consistent with glomerulonephritis B. Inconsistent with glomerulonephritis C. Indicative of impending kidney failure D. Unclear, and no conclusion can be drawn
A. Consistent with glomerulonephritis Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky in color from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal elevated blood urea nitrogen, creatinine, C-reactive protein level, and antistreptolysin O titer.
The nurse is caring for a client with Buck's traction and is monitoring the client for complications of the traction. Which assessment finding indicates a complication? A. Weak pedal pulses B. Drainage at the pin sites C. Complaints of discomfort D. Warm toes with brisk capillary refill
A. Weak pedal pulses Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. On further assessment, the nurse notes that the client experiences more pain during passive motion of the left arm than with active motion. Based on these assessment findings, which action should the nurse take? A. Contact the health care provider. B. Reassess the client in 30 minutes. C. Check to see if it is time for more pain medication. D. Encourage the client to continue with active range of motion exercises to the left arm.
A. Contact the health care provider. The client with early acute compartment syndrome typically complains of severe, diffuse pain that is unrelieved with pain medication. The client also complains that pain during passive motion is greater than during active motion. The nurse notifies the health care provider immediately. Options 2, 3, and 4 are inaccurate interventions
The nurse is monitoring a closed chest tube drainage system. The nurse suspects an air leak in the system if which finding is noted? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the water seal chamber C. Continuous bubbling in the suction control chamber D. Intermittent bubbling in the suction control chamber
A. Continuous bubbling in the water seal chamber
A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A. Dyspnea B. Bradypnea C. Bradycardia D. Decreased respirations
A. Dyspnea
The nurse receives a client from the postanesthesia care unit (PACU) following an above-the-knee amputation. Which action should the nurse take to safely position the client? A. Elevate the foot of the bed. B. Put the bed in reverse Trendelenburg. C. Position the residual limb flat on the bed. D. Keep the residual limb flat with the client lying on the operative side.
A. Elevate the foot of the bed.
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs? A. Numbness and tingling are felt in the fingers. B. The cast feels heavy and damp after 24 hours of application. C. The entire cast feels warm during the first 24 hours after application. D. Slightly bloody drainage is noted on the cast during the first 6 hours after application
A. Numbness and tingling are felt in the fingers.
The nurse is monitoring the function of a client's chest tube. The chest tube is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding? A. There is a leak in the system. B. Suction should be added to the system. C. This is caused by client pneumothorax. D. Water should be added to the chamber.
D. Water should be added to the chamber.
The nurse is planning care for a client with a chest tube drainage system. The nurse should include which interventions in the plan? Select all that apply. A. Clamping the chest tube intermittently B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates E. Taping the connection between the chest tube and the drainage system
B, C, D, E Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.
On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breaths sound in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub
B. Absence of breaths sound in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse should determine that there is a need for close observation and a need for follow-up if which is noted? A. Palpable pulses distal to the cast B. Capillary refill greater than 6 seconds C. Blanching of the nail bed when it is depressed D. Sensation when the area distal to the cast is pinched
B. Capillary refill greater than 6 seconds
The nurse is assigned to care for a client who is in traction. How can the nurse ensure a safe environment for the client? A. Making sure that the knots are at the pulleys B. Checking the weights to be sure that they are off the floor C. Making sure that the head of the bed is kept at a 90-degree angle D. Monitoring the weights to be sure that they are resting on a firm surface
B. Checking the weights to be sure that they are off the floor
The nurse is performing pin site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites? A. Loose pin sites B. Clear drainage from the pin sites C. Purulent drainage from the pin sites D. Redness and swelling around the pin sites
B. Clear drainage from the pin sites A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted the health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A. Inform the physician B. Continue to monitor the client C. Reinforce the occlusive dressing D. Encourage the client to deep-breathe
B. Continue to monitor the client The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
An adult client newly admitted to the hospital with a fractured femur is placed in skin traction while awaiting surgery. The nurse recognizes that the traction is applied for which purpose? A. Preventing hip contracture B. Decreasing muscle spasms C. Inhibiting bone ossification D. Resisting peroneal nerve damage
B. Decreasing muscle spasms
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury
B. Diminished breath sounds
The nurse is going to suction an adult client with a tracheostomy who has copious amounts of respiratory secretions. Which intervention should the nurse take to perform this procedure safely? A. Set the suction pressure range between 160 to 180 mm Hg. B. Hyper-oxygenate the client using a manual resuscitation bag. C. Apply continuous suction in the airway for up to 20 seconds. D. Occlude the Y-port of the suction catheter while advancing it into the tracheostomy.
B. Hyper-oxygenate the client using a manual resuscitation bag.
A client with glomerulonephritis is at risk of developing acute kidney injury. Which sign of this complication should the nurse assess this client for? A. Bradycardia B. Hypertension C. Decreased cardiac output D. Decreased central venous pressure
B. Hypertension Acute kidney injury caused by glomerulonephritis is classified as intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure (or a recent history of the same), tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not associated with acute kidney injury.
A client has undergone a left above-the-knee amputation. The nurse interprets that this client is especially at risk for which complication because of a concurrent history of diabetes mellitus? A. Left hip contracture B. Infection in the incision C. Bleeding from the incision D. Edema of the residual limb
B. Infection in the incision
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. Pallor B. Low arterial PaO2 C. Elevated arterial PaO2 D. Decreased respiratory rate
B. Low arterial PaO2 The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A client with compartment syndrome in the leg has undergone fasciotomy. The nurse reads the health care provider prescription sheet, anticipating a prescription for which type of dressings to be used on this wound? A. Occlusive dressing B. Moist, sterile saline dressing C. Dry, sterile dressing wrapped with an elastic bandage D. Betadine-soaked dressing covered with a plastic wrap
B. Moist, sterile saline dressing fasciotomy site is not sutured, but it is left open to relieve pressure and edema. The site is covered with moist, sterile, saline dressings because underlying tissue is exposed. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. The other types of dressings are not used on a fasciotomy site.
The nurse is preparing a plan of care for the client in Buck's traction. The nurse includes in the plan that a priority intervention is to assess the client frequently for which assessment finding? A. Urinary incontinence B. Signs of skin breakdown C. The presence of bowel sounds D. Signs of infection around the pin sites
B. Signs of skin breakdown Buck's traction is a form of skin traction. Skin traction is achieved by ace wraps, boots, and slings that apply a direct force on the client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 pounds of weight (depending on the health care provider's prescription), and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Assessment of bowel sounds may be a component of the assessment because constipation can occur as a result of immobility. However, this is not the priority assessment. There are no pin sites with skin traction
The nurse is determining the need for suctioning in a client with an endotracheal (ET) tube attached to a mechanical ventilator. Which observation by the nurse indicates this need? A. Clear breath sounds B. Visible mucus bubbling in the ET tube C. Apical pulse rate of 72 beats per minute D. Low peak inspiratory pressure on the ventilator
B. Visible mucus bubbling in the ET tube Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.
A client with a fractured femur is placed in skeletal traction. What should the nurse do to monitor for nerve injury? A. Check the blood pressure. B. Check the pin sites for drainage. C. Assess the neurovascular status of the affected extremity. D. Monitor the client's ability to perform active range of motion to the affected extremity.
C. Assess the neurovascular status of the affected extremity.
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A. 1 minute B. 5 seconds C. 10 seconds D. 30 seconds
C. 10 seconds
Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function? 1. Obtain an order for a chest x-ray to document tube placement. 2. Confirm that the breath sounds are equal and bilateral. 3. Auscultate the chest during assisted ventilation. 4. Secure the tube in place. A. 1, 2, 3, 4 B. 4, 3, 2, 1 C. 3, 2, 4, 1 D. 4, 1, 2, 3
C. 3, 2, 4, 1 Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.
The nurse is caring for the following group of clients on the clinical nursing unit. Which of these clients does the nurse interpret to be most at risk for the development of pulmonary embolism? A. A 25-year-old woman with diabetic ketoacidosis B. A 65-year-old man out of bed 1 day after prostate resection C. A 73-year-old woman who has just had a pinning of a hip fracture D. A 38-year-old man with a closed pneumothorax after an auto accident
C. A 73-year-old woman who has just had a pinning of a hip fracture Pulmonary embolism occurs when a thrombus forms, detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery. Clients frequently at risk for pulmonary embolism include those who are immobilized, especially postoperative clients. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, and advancing age.
The nurse receives a telephone call from the emergency department and is told that a client in leg traction will be admitted to the nursing unit. The nurse prepares for the arrival of the client and asks the unlicensed assistive personnel to obtain which item that will be essential for helping the client move in bed while in leg traction? A. A foot board B. Extra pillows C. A bed trapeze D. An electric bed
C. A bed trapeze A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.
A client with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What should the nurse implement for this procedure to be most effective? A. Obtain baseline arterial blood gases. B. Obtain baseline pulse oximetry levels. C. Apply the mask to the face with a snug fit. D. Encourage the client to remove the mask frequently for coughing and deep breathing exercises.
C. Apply the mask to the face with a snug fit. The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.
The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after a renal transplant. The nurse should plan to carefully monitor which laboratory result for this client? A. Potassium B. Magnesium C. Blood glucose D. Serum albumin
C. Blood glucose
The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician? A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation. B. Drainage system maintained below the client's chest. C. Drainage amount of 100ml in the drainage collection chamber. D. Occlusive dressing in place over the chest tube insertion site
C. Drainage amount of 100ml in the drainage collection chamber. Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.
A client has 2 chest tubes inserted into the right pleural space after thoracic surgery; the tubes are attached to chest drainage systems. To promote optimal respiratory functioning, which intervention should the nurse include when developing a plan of care? A. Milk and strip the chest tubes once a shift. B. Position the client only on the back and on the right side. C. Encourage the client to cough and deep breathe every hour. D. Maintain the client on bedrest until the chest tubes are removed.
C. Encourage the client to cough and deep breathe every hour.
A client returns from the recovery room after insertion of skeletal pins and application of leg traction to treat a fracture. Initially, how often should the nurse assess the neurovascular status of the client's affected leg? A. Every 2 hours B. Every shift C. Every hour D. Every 4 hours
C. Every hour
The home care nurse is making follow-up visits to a client after renal transplant. The nurse should assess the client for which manifestations of acute graft rejection? A. Hypotension, graft tenderness, and anemia B. Hypertension, oliguria, thirst, and hypothermia C. Fever, hypertension, graft tenderness, and malaise D. Fever, vomiting, hypotension, and copious amounts of dilute urine output
C. Fever, hypertension, graft tenderness, and malaise
A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? A. Cardiogenic. B. Distributive. C. Hypovolemic. D. Obstructive.
C. Hypovolemic. -Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. -Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure. -Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation. -Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which has provided very little pain relief. The nurse determines that this pain is caused by which factor? A. Infection under the cast B. The anxiety of the client C. Impaired tissue perfusion D. The newness of the fracture
C. Impaired tissue perfusion
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which earliest clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor for? A. Cyanosis and pallor B. Diffuse crackles and rhonchi on chest auscultation C. Increase in respiratory rate from 18 to 30 breaths per minute D. Haziness or "white-out" appearance of lungs on chest radiograph
C. Increase in respiratory rate from 18 to 30 breaths per minute ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or "white-out" appearance in the later stages.
A male patient's X-ray result reveals bilateral white-outs, indicating acute respiratory distress syndrome (ARDS). This syndrome results from: A. Cardiogenic pulmonary edema B. Respiratory alkalosis C. Increased pulmonary capillary permeability D. Renal failure
C. Increased pulmonary capillary permeability ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry. B. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline. C. Gently cleansing the amputated digits and the hand with povidone-iodine. D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.
D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.
The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take? A. Secure the chest tube using a tape. B. Clamp the chest tube immediately. C. Place the end of the chest tube in a container of normal sterile saline. D. Apply an occlusive dressing and notify the physician
C. Place the end of the chest tube in a container of normal sterile saline. If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected
A client is being discharged to home while recovering from acute kidney injury. The client demonstrates an understanding of the therapeutic dietary regimen when indicating a need to limit which dietary factor? A. Fats B. Vitamins C. Potassium D. Carbohydrates
C. Potassium
A client with acute kidney injury has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse evaluates this therapy as effective if which values were noted on follow-up laboratory testing? A. Calcium: 9.8 mg/dL B. Sodium: 142 mEq/L C. Potassium: 4.9 mEq/L D. Phosphorus: 3.9 mg/dL
C. Potassium: 4.9 mEq/L
The nurse assesses a client who was involved in a motor vehicle crash. Which manifestations, if exhibited by the client, should lead the nurse to determine the need to prepare for chest tube insertion? A. Chest pain and shortness of breath B. Peripheral cyanosis and hypotension C. Shortness of breath and tracheal deviation D. Decreasing oxygen saturation and bradypnea
C. Shortness of breath and tracheal deviation Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. The trachea deviates to the unaffected side in the presence of a tension pneumothorax. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from a decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal shift and impedance of venous return to the heart. However, it may also be the result of other problems, such as a failing heart. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? A. Continue to suction B. Notify the physician immediately C. Stop the procedure and reoxygenate the client D. Ensure that the suction is limited to 15 seconds
C. Stop the procedure and reoxygenate the client
The nurse is caring for a client on a mechanical ventilator that is set on intermittent mandatory ventilation (IMV) mode at a rate of 8 breaths per minute. The nurse assesses the respiratory rate of the client and notes that it is 12 breaths per minute. How should the nurse interpret this assessment finding? A. The client is "fighting" the ventilator. B. The client is receiving pressure support ventilation. C. The client is breathing four additional breaths on his own. D. The client is receiving additional breaths by the ventilator
C. The client is breathing four additional breaths on his own. In the intermittent mandatory ventilation (IMV) mode, the ventilator delivers a preset number of mechanical breaths. However, it allows the client to breathe spontaneously in between the mechanical breaths with no assistance from the ventilator and at varying tidal volumes. Therefore, if the nurse assesses the respiratory rate to be 12 breaths per minute and the IMV mode is set at 8 breaths per minute, the client is breathing 4 additional breaths on her own. If the client were fighting the ventilator, the mechanical breaths would be at the preset level or possibly lower. The client is only being assisted by the ventilator for the preset 8 breaths per minute. The ventilator is not providing additional breaths to the client.
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally B. The client has a pneumothorax C. The system has an air leak D. The chest tube is obstructed
C. The system has an air leak
A client is being treated in the emergency department for a fractured tibia. The skin is not broken, but the nurse can see on the x-ray viewer that the bone is completely fractured across the shaft and has small splintered pieces around it. What kind of fracture did the client sustain? A. Simple fracture B. Greenstick fracture C. Compound fracture D. Comminuted fracture
D. Comminuted fracture
This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the assessment data and determines that the client's symptoms indicate what condition? A. Fat embolism B. Venous thrombosis C. Osteomyelitis D. Compartment syndrome
D. Compartment syndrome
A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event? A. Bleeding ulcer B. Myocardial infarction C. Deep vein thrombosis D. Streptococcal infection
D. Streptococcal infection The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.
A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching? A. "I can use the blunt part of a ruler to scratch the area." B. "I can trickle small amounts of water down inside the cast." C. "I need to obtain assistance when placing an object into the cast for the itching." D. "I can use a hair dryer on the low setting and allow the air to blow into the cast."
D. "I can use a hair dryer on the low setting and allow the air to blow into the cast."
A client undergoing hemodialysis becomes hypotensive. What action should the nurse immediately prepare to take? A. Administer 100 mL D5W. B. Lower the client's legs and feet. C. Increase the blood flow into the dialyzer. D. Administer a 250-mL normal saline bolus.
D. Administer a 250-mL normal saline bolus. To treat hypotension during hemodialysis, a normal saline bolus of up to 500 mL may be given. D5W is not prescribed because it is less likely to improve the circulating volume and blood pressure. The client's feet and legs are raised to enhance cardiac return. Albumin may be given as per protocol to increase colloid oncotic pressure. The blood flow rate into the dialyzer may be decreased. All these measures should improve the circulating volume and blood pressure.
The nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. What should the nurse check to perform a complete neurovascular assessment of the affected extremity? A. Vital signs and bilateral lung sounds B. Warmth of the skin and the temperature in the affected extremity C. Pain level and for the presence of edema in the affected extremity D. Color, sensation, movement, capillary refill, and pulse of the affected extremity
D. Color, sensation, movement, capillary refill, and pulse of the affected extremity
The nurse is caring for a client newly diagnosed with chronic kidney disease who has recently begun hemodialysis. The nurse determines that the client has not tolerated the procedure optimally if the client experiences which symptoms that represent disequilibrium syndrome? A. Hypertension, tachycardia, and fever B. Hypotension, bradycardia, and hypothermia C. Restlessness, irritability, and generalized weakness D. Headache, deteriorating level of consciousness, and seizures
D. Headache, deteriorating level of consciousness, and seizures Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from the rapid removal of solutes from the body during hemodialysis. The blood-brain barrier interferes with equally efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and it is prevented by dialyzing for shorter times or at reduced blood flow rates.
A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications? A. Trim the rough edges of the cast after it is dry. B. Weight bearing on the right leg is allowed once the cast feels dry. C. Expect burning and tingling sensations under the cast for 3 to 4 days. D. Keep the right ankle elevated above the heart level with pillows for 24 hours
D. Keep the right ankle elevated above the heart level with pillows for 24 hours Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to "petal" the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A. Exhale slowly B. Stay very still C. Inhale and exhale quickly D. Perform the Valsalva maneuver
D. Perform the Valsalva maneuver
The nurse is assigned to care for a client who is 2 days postoperative following an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures? A. Maintains a supine position B. Elevates the stump on a pillow C. Maintains a high Fowler's position when the client is in bed D. Positions the client on the abdomen for 20 to 30 minutes twice a day
D. Positions the client on the abdomen for 20 to 30 minutes twice a day To prevent hip contractures, the health care provider may prescribe that the client be placed prone for 20 to 30 minutes twice a day. A high Fowler's position will promote flexion contractures. For the first 24 hours postoperatively, the health care provider usually prescribes elevation of the limb to decrease swelling and promote comfort. Stumps with compromised circulation should not be elevated. Elevation is then done at intervals because elevation for longer periods of time may cause flexion contractures of the hip
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of infection? A. Dependent edema B. Diminished distal pulse C. Coolness and pallor of the skin D. Presence of warm areas on the cast
D. Presence of warm areas on the cast Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
A client having a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, Pco2 31 mm Hg, Pao2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
D. Respiratory alkalosis
A client with a history of chronic infection of the urinary system complains of burning and urinary frequency. To determine whether the current problem is of renal origin, what area should the nurse assess the client for pain or discomfort? A. Urinary meatus B. Suprapubic area C. Pain in the labium D. Right or left costovertebral angle
D. Right or left costovertebral angle
A client with a flail chest caused by four fractured rib segments is experiencing severe pain when trying to breathe. Which characteristics of a flail chest should the nurse observe the client for? A. Cyanosis and slow respirations B. Slight bradypnea with shallow breaths C. Pallor and paradoxical chest movement D. Severe dyspnea and paradoxical chest movement
D. Severe dyspnea and paradoxical chest movement
