Respiratory
When a client with laryngeal cancer has a laryngectomy scheduled, which action will the nurse include in the postoperative teaching plan?
A. Importance of cleanliness around the site of the stoma
B. Necessity of blocking the tube opening while swimming
C. Establishment of a regular schedule for suctioning the tube
D. Usage of sterile technique when caring for the tracheostomy tube
A. Importance of cleanliness around the site of the stoma
The procedure should be explained so the client understands that the tracheostomy can serve as an entrance for bacteria and that cleanliness is imperative. After laryngectomy, the client’s airway ends at the stoma, which cannot be blocked. Clients with a laryngectomy do not swim because of the high risk for water entering the airway. Suctioning must be performed only as needed; a pattern is not necessary. Sterile technique is not required; medical aseptic technique is adequate and realistic.
After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral?
A. Potassium
B. Calcium
C. Magnesium
D. Sodium
B. Calcium
The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia. Deficits in potassium, magnesium, and sodium do not cause these classic manifestations.
When a client is admitted to the emergency department with disseminated intravascular coagulation caused by sepsis, which prescribed action will the nurse take first?
A. Apply antiembolism stockings.
B. Draw blood for culture and sensitivity.
C. Administer vancomycin 1 gram intravenously.
D. Transfer the client to the intensive care unit.
B. Draw blood for culture and sensitivity.
Treatment of disseminated intravascular coagulation focuses on treatment of the cause of the abnormal coagulation, so rapid initiation of antibiotic therapy is essential. However, blood cultures are drawn before antibiotic administration to ensure that appropriate antibiotics can be prescribed. Antiembolism stockings are needed to help prevent venous thrombosis, but are not the priority action. The client needs to be transferred to the intensive care unit, but the nurse would not wait for the transfer to obtain cultures and administer antibiotics.
When a client with a large abdominal aortic aneurysm is admitted for elective surgery, which clinical finding would the nurse expect when completing the admission assessment?
A. Elevated heart rate
B. Visible peristaltic waves
C. Radiating abdominal pain
D. Pulsating abdominal mass
D. Pulsating abdominal mass
With an abdominal aortic aneurysm, a pulsating midline mass can be palpated with each heartbeat. Signs of shock such as tachycardia would not be expected unless the aneurysm ruptures or dissects. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not typical for an abdominal aortic aneurysm, but may be seen with enlargement or rupture of the aneurysm.
For which acute, life-threatening complication would the nurse monitor during the client’s early postoperative period after a radical nephrectomy?
A. Sepsis
B. Hemorrhage
C. Renal failure
D. Paralytic ileus
B. Hemorrhage
The kidney, an extremely vascular organ, receives a large percentage of the blood flow. Hemorrhage from the operative site is a potential complication. Sepsis and renal failure may occur later in the postoperative period. Paralytic ileus can occur, but it is not life threatening.
Which assessments are the most significant for a client who is believed to have myasthenia gravis?
A. Capacity to smile and close the eyelids
B. Ability to chew and speak words distinctly
C. Effectiveness of respiratory exchange and ability to swallow
D. Degree of anxiety and concern about the suspected diagnosis
C. Effectiveness of respiratory exchange and ability to swallow
Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.
Which action would be the nurse’s first priority when receiving a client with major burns?
A. Assessing airway patency
B. Checking the client from head to toe
C. Administering oxygen as needed
D. Elevating the extremities if no fractures are noticed
A. Assessing airway patency
The first action of the nurse for a client with major burns should be assessing airway patency because airway obstruction will lead to the death of the client. Other subsequently important actions of the nurse for the client should be assessment of the client from head to toe. The client should be administered oxygen according to need. The extremities should be elevated if there are no fractures.
A client is admitted with metabolic acidosis. Which two body systems would the nurse assess for compensatory changes?
A. Skeletal and nervous
B. Circulatory and urinary
C. Respiratory and urinary
D. Muscular and endocrine
C. Respiratory and urinary
Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps adjust the body’s pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.
Which assessment finding by the nurse indicates that the treatment for a client with cor pulmonale has been effective?
A. Weight gain
B. Increased heart rate
C. Reduction of hemoptysis
D. Decreased peripheral edema
D. Decreased peripheral edema
Cor pulmonale is right ventricular failure usually caused by pulmonary hypertension associated with chronic obstructive pulmonary disease. Improvement in peripheral edema would indicate that treatment had been effective. Fluid retention in cor pulmonale causes weight gain; clients would be expected to lose weight as fluid retention decreases with effective treatment. Because heart rate is typically increased in cor pulmonale, a decrease in heart rate would be associated with successful therapy. Hemoptysis is not a clinical manifestation of cor pulmonale, although hemoptysis is seen in infectious lung diseases such as pneumonia and tuberculosis.
Which interventions would the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct.
A. Provide frequent oral care.
B. Institute fall risk precautions.
C. Restrict fluids to 2 L per day.
D. Place the client in high-Fowler position.
E. Monitor for and report neurological changes.
A. Provide frequent oral care.
B. Institute fall risk precautions.
E. Monitor for and report neurological changes.
The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output, increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk precautions are instituted to protect the client from injury that might occur as a result of neurological changes associated with declining serum sodium. The nurse monitors for and reports changes in neurological status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that antidiuretic hormone release should be decreased.
A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube would the nurse anticipate will most likely be used to meet the needs of this client?
A. Levin
B. Salem sump
C. Miller-Abbott
D. Sengstaken-Blakemore
D. Sengstaken-Blakemore
Sengstaken-Blakemore includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. A Miller-Abbott tube is used for intestinal decompression.
Which findings will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery? Select all that apply.
A. Hypertension
B. Pulsus paradoxus
C. Muffled heart sounds
D. Jugular vein distention
E. Increased urine output
B. Pulsus paradoxus
C. Muffled heart sounds
D. Jugular vein distention
Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the cardiac output decreases, there is a decrease in kidney perfusion and a decrease in urine output.
Which clinical indicators would the nurse expect for a client who has end-stage renal disease (ESRD)?
Select all that apply.
A. Polyuria
B. Jaundice
C. Azotemia
D. Hypertension
E. Polycythemia
C. Azotemia
D. Hypertension
Azotemia is an increase in nitrogenous waste, particularly urea, in the blood; this is common in ESRD. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the renin-angiotensin-aldosterone system. Excessive nephron damage in ESRD causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not ESRD. Anemia, not polycythemia, occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.
Which lobe of the cerebrum includes the Broca speech center?
A. Frontal lobe
B. Parietal lobe
C. Occipital lobe
D. Temporal lobe
A. Frontal lobe
The Broca speech center is located in the frontal lobe and is responsible for the formation of words into speech. The parietal lobe aids in processing of spatial awareness and receiving and processing information about temperature, taste, and touch. The primary visual center is in the occipital lobe. The auditory center for interpreting sound is present in the temporal lobe.
Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed?
A. Increasing mobility
B. Preventing contractures
C. Limiting orthostatic hypotension
D. Preventing pressure on peripheral blood vessels
D. Preventing pressure on peripheral blood vessels
The circulating air bed disperses body weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue perfusion. These beds are used for clients who are immobile; they do not increase mobility. Limiting orthostatic hypotension is achieved by dangling, not by this type of bed. Range-of-motion exercises, not the type of bed, will help prevent contracture.
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client? Select all that apply.
A. Fever
B. Tachypnea
C. Hypertension
D. Abdominal rigidity
E. Increased bowel sounds
A. Fever
B. Tachypnea
D. Abdominal rigidity
The metabolic rate will be increased, and the temperature-regulating center in the hypothalamus resets to a higher-than-usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.
A client experiences a right-sided pneumothorax. The nurse recognizes that there is danger of a mediastinal shift, which could cause which life-threatening condition?
A. Rupture of the pericardium
B. Infection of the subpleural lining
C. Decreased filling of the right side of the heart
D. Increased volume of the unaffected lung
C. Decreased filling of the right side of the heart
Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Rupture of the pericardium might occur with severe chest trauma, not with a mediastinal shift. Infection is not caused by a mediastinal shift. The volume of the unaffected lung may decrease because of pressure from the shift.
Which nursing intervention is appropriate to include in the plan of care for a client with diabetic ketoacidosis (DKA)?
A. Intravenous administration of regular insulin
B. Administer insulin glargine subcutaneously at hour of sleep
C. Maintain nothing prescribed orally (NPO) status
D. Intravenous administration of 10% dextrose
A. Intravenous administration of regular insulin
A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client’s blood glucose.
When a client with acute myelocytic leukemia who is receiving chemotherapy develops tumor lysis syndrome, the nurse will anticipate a need to implement which collaborative action?
A. Offer analgesics frequently.
B. Infuse large amounts of fluids.
C. Administer antibiotic therapy.
D. Give anticoagulant medication.
B. Infuse large amounts of fluids.
Tumor lysis syndrome occurs when chemotherapy destroys large numbers of abnormal cells quickly, leading to high levels of potassium and uric acid and the risk for hyperkalemia and acute kidney injury. Hydration prevents and manages tumor lysis syndrome by dilution, lowering potassium and uric acid levels, increasing potassium excretion, and preventing kidney stones. More frequent analgesia is will not treat tumor lysis syndrome. Antibiotics are used to treat infection and sepsis associated with leukemia, but are not a treatment for tumor lysis syndrome. Anticoagulant medications are not used to treat tumor lysis syndrome.
Which information about a client who is being discharged 3 days after having an ST segment elevation myocardial infarction (STEMI) and coronary artery stent placement indicates that a home health referral may be needed at discharge?
A. ST segments have not yet returned to baseline.
B. Troponin T and Troponin I levels are still elevated.
C. Client reports frequently forgetting to take medications.
D. Pulse increases from 65 beats/minute to 75 beats/minute with exercise.
C. Client reports frequently forgetting to take medications.
Because clients are discharged on multiple medications after experiencing STEMI and stenting, the statement about forgetting to take medications indicates a need for home health assessment and interventions to ensure medication adherence. ST segments may not return to baseline for a few days after STEMI. Troponin levels remain elevated for 10 to 14 days post-STEMI. A pulse rate increase of 10 beats/minute is a normal response to exercise.
A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client’s wife indicates that further teaching is required?
A. "I must touch the shunt several times a day to feel for the bruit."
B. "I have to take his blood pressure every day in the arm with the fistula."
C. "He will have to be very careful at night not to lie on the arm with the fistula."
D. "We really should check the fistula every day for signs of redness and swelling."
B. "I have to take his blood pressure every day in the arm with the fistula."
Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Hemorrhage can occur in a matter of minutes if the cannula is dislodged. It is correct that the patient should not lie on the arm with the fistula. Redness and swelling are signs of infection, which is a complication of cannulization.
A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client’s cardiac output? Record your answer using a whole number.
_____ mL/min
5040 mL/min
Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client’s urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take?
A. Give the client orange juice by mouth.
B. Increase the client’s intravenous (IV) flow rate.
C. Moisten the client’s lips with a wet 4 × 4 gauze.
D. Offer the client 4 oz (120 mL) of water by mouth.
C. Moisten the client’s lips with a wet 4 × 4 gauze.
No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary health care provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary health care provider’s prescription.
Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis?
A. Assessing the nail beds
B. Listening to breath sounds
C. Monitoring breathing status
D. Checking muscle contractions
C. Monitoring breathing status
The nursing priority for preventing complications when caring for clients with respiratory acidosis is to monitor breathing status hourly and intervening changes. Assessing the nail beds for cyanosis, which is usually a late finding in acidosis, is not a priority intervention. Listening to breath sounds and assessing how easily air moves into and out of the lungs can be a second priority intervention. Checking muscle contractions in the neck region is a later priority intervention.
Which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube?
A. Palpate around the tube insertion sites for crepitus.
B. Auscultate the breath sounds for crackles and atelectasis.
C. Observe the client for the presence of a barrel-shaped chest.
D. Compare the length of inspiration with the length of expiration.
A. Palpate around the tube insertion sites for crepitus.
Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.
Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
A. Providing oxygen
B. Encouraging carbohydrates
C. Administering fluid replacement
D. Teaching facts about dietary principles
C. Administering fluid replacement
As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.
On the first day after a mastectomy, the nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. How would the nurse respond to the client’s question as to why she needs to do these exercises?
A. "They preserve muscle tone."
B. "They prevent joint contractures."
C. "They help us assess the extent of lymphedema."
D. "They will help stimulate peripheral circulation."
D. "They will help stimulate peripheral circulation."
These exercises require muscle contractions that put pressure on blood vessels; muscle contraction promotes circulation, increasing tissue oxygen. Decline in muscle tone (atrophy) is not a common complication after mastectomy. Contractures are a rare complication after a mastectomy. Lymphedema is assessed by measuring the circumference of the extremity, not by having the client exercise.
The nurse needs to administer lidocaine HCl at 1.5 mg per minute. The medication is available as 500 mg in 100 mL of D5W. The nurse will set the intravenous (IV) infusion pump to deliver how many milliliters per hour? Record your answer using a whole number. ___ mL/h
18 mL/h
When teaching the signs of organ rejection to a client with a recent renal transplant, which sign indicates the transplant is not working?
A. Weight loss
B. Subnormal temperature
C. Blood pressure.
D. Increased urinary output
C. Blood pressure.
Hypertension is a clinical manifestation of a failed or failing kidney transplant. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The client will have an elevated temperature exceeding 100°F (37.8°C) with kidney rejection. Urine output will be decreased or absent, depending on the degree of kidney rejection.
When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply.
A. Bradycardia
B. Hypotension
C. Spastic paralysis
D. Urinary retention
E. Increased pulse pressure
A. Bradycardia
B. Hypotension
D. Urinary retention
Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply.
A. Monitoring vital signs
B. Cutting off the clothing
C. Inserting a urinary catheter
D. Removing the client’s jewelry
E. Establishing an intravenous line
A. Monitoring vital signs
B. Cutting off the clothing
C. Inserting a urinary catheter
D. Removing the client’s jewelry
E. Establishing an intravenous line
According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client’s clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.
Which lung sound would the nurse expect to hear in a client who experiences laryngeal swelling after extubation?
A. Stridor
B. Wheeze
C. Crackles
D. Rhonchi
A. Stridor
Stridor is a crowing sound usually heard during inspiration that frequently can be heard without a stethoscope and indicates upper airway obstruction. Wheezes are high-pitched sounds heard with obstruction of the lower airways and are initially heard more during expiration as the airways collapse. Crackles are heard over the lower lung fields and occur with air movement through secretions or fluid in the alveoli. Rhonchi are lower-pitched sounds heard with obstruction of the lower airways.
Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the most rapid action by the nurse?
A. Oxygen saturation of 93%
B. Blood pressure of 160/94 mm Hg
C. Decreased right side breath sounds
D. Ecchymosis at the site of the thoracentesis
C. Decreased right side breath sounds
After thoracentesis the breath sounds should be audible on the affected side and decreased breath sounds may indicate pneumothorax. The nurse would immediately notify the health care provider and expect actions such as a chest x-ray and possible insertion of a chest tube. The oxygen saturation of 93% is slightly below normal, but would not be surprising in a client who has a history of lung disease. Hypotension after thoracentesis may indicate bleeding or that too much pleural fluid has been removed at once, but mild hypertension may occur due to anxiety or pain. Ecchymosis at the thoracentesis site would be monitored, but would be expected after thoracentesis.
In the Emergency Department (ED), an insulin infusion was prepared with 100 units of regular insulin in a 100 mL of 0.9% sodium chloride to achieve a concentration of 1 unit/1 mL. To deliver 5 units per hour, the IV pump was set to deliver _____ mL per hour.
5 mL/hr
Which activity would the nurse include when teaching adults about activities that increase the risk of developing bladder cancer?
A. Jogging 3 miles (4.8 km) a day
B. Drinking three cans of cola a day
C. Smoking two packs of cigarettes a day
D. Using a jackhammer and chainsaw every day
C. Smoking two packs of cigarettes a day
The occurrence of bladder cancer is related to smoking. Dyes in rubber and hair dyes are environmental carcinogens; working with them daily increases an individual’s risk of bladder cancer. Jogging is unrelated to the development of cancer of the bladder. Ingestion of cola has not been linked to cancer of the bladder. Vibrations may result in musculoskeletal or kidney problems but are unrelated to cancer of the bladder.
While waiting in the preoperative holding area for endovascular repair of an abdominal aortic aneurysm, a client suddenly reports lightheadedness and blood pressure drops. Which action would the nurse take first?
A. Prepare for blood transfusions.
B. Notify the surgeon immediately.
C. Ensure that the surgical consent form is signed.
D. Administer the prescribed preoperative sedative.
B. Notify the surgeon immediately.
Because the client’s symptoms indicate likely rupture of the aneurysm, immediate surgical intervention is needed. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. Surgical consent will be obtained, but the surgeon needs to be rapidly available to intervene. Preoperative medications will eventually be administered, but they mask clinical manifestations of shock and would not be given until the health care provider evaluates the client.
A client receiving peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution. Which action would the nurse take?
A. Increase the rate of infusion.
B. Auscultate the lungs for breath sounds.
C. Place the client in a supine position.
D. Drain the fluid from the peritoneal cavity.
D. Drain the fluid from the peritoneal cavity.
Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration. Additional fluid will aggravate the problem. Auscultation is important, but it does not alleviate the problem. The client should be placed in the semi-Fowler position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.
Which nursing action is a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia?
A. Place in a sitting position.
B. Give nifedipine as prescribed.
C. Examine for symptoms of pressure injuries.
D. Monitor blood pressure (BP) every 10 to 15 minutes.
A. Place in a sitting position.
Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high BP. The first step in this situation is to assist the client into a sitting position because it naturally reduces BP. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure injuries after stabilizing the client. The nurse would monitor client’s BP every 10 to 15 minutes after stabilizing the client.
The nurse is caring for a client during the emergent phase after the client sustained serious burns that involved a large surface of the skin. Which nursing intervention is the priority during this phase?
A. Alleviating pain
B. Preventing infection
C. Replacing blood loss
D. Restoring fluid volume
D. Restoring fluid volume
In the first 48 hours after a severe burn, fluid moves into the tissues surrounding the injured area. Fluid also is lost in drainage and from evaporation; this fluid loss results in a decreased circulating blood volume, which can cause hypovolemic shock. Although pain relief is an important aspect in the care of clients with burns, the immediate priority is to replace fluid losses to prevent death. If fluid losses are not replaced immediately, the client may die before the development of an infection. Blood loss usually is minimal; the loss of fluid, colloids, and electrolytes is what causes the hypovolemia.
Which nursing interventions would be appropriate for clients who suffocated due to smoke inhalation during a fire who have absent breath sounds?
Select all that apply.
A. Using the jaw-thrust maneuver
B. Preparing to intubate
C. Removing or suctioning any foreign bodies
D. Preparing for needle thoracostomy and chest tube insertion
E. Inserting oropharyngeal or nasopharyngeal airway, endotracheal tube, and cricothyroidotomy
B. Preparing to intubate
D. Preparing for needle thoracostomy and chest tube insertion
Suffocation occurs due to lack of oxygen supply to the body. Preparing for intubation is necessary when there is severe respiratory distress or arrest. Needle thoracostomy and chest tube insertion is performed to reduce the pneumothorax tension that may occur in the event of absent breath sounds. Jaw-thrust maneuver is used to open the airway of an unconscious client when there is a neck or spinal injury, not during respiratory distress. Removing or suctioning foreign bodies is performed when assessing the airway with simultaneous cervical spine immobilization. Intubation is not within the scope of practice for registered nurses in all states.