The nurse is caring for a two-year-old client who presented to the ER with vomiting, currant jelly-like stools, and abdominal pain that causes the child to draw the knees up to the abdomen in a fetal position. Which interventions does the nurse anticipate for this client?
Rationale:
The nurse anticipates monitoring for a normal, brown stool, preparing the client for a barium enema, placement of a nasogastric (NG) tube, and monitoring for fever and changes in blood pressure.
C: Monitoring for a normal, brown stool is essential as the child's symptoms indicate a possible obstruction, and normal stool consistency is a key indicator of gastrointestinal health.
D: Preparing the client for a barium enema facilitates diagnostic imaging to visualize intestinal obstructions, making it a critical intervention in managing the child's acute symptoms.
E: Placement of a nasogastric (NG) tube helps decompress the stomach and manage vomiting, which is vital in preventing further complications from the child’s current condition.
F: Monitoring for fever and changes in blood pressure provides vital signs necessary to assess for infection or shock, both significant concerns in a child presenting with these gastrointestinal symptoms.
The nurse is caring for a client who is on 2 L/minute of oxygen via nasal cannula. The nurse understands that this flow rate corresponds to which FiO2?
Rationale:
2 L/minute of oxygen via nasal cannula corresponds to 28% FiO2. This is based on the general rule that each liter of oxygen increases the FiO2 by approximately 4%, leading to 28% at 2 L/min.
A: 24% FiO2. This percentage reflects a lower flow rate of oxygen, typically associated with 1 L/min, which does not match the given 2 L/min rate.
C: 32% FiO2. This level of oxygen saturation would require a higher flow rate, likely around 3 L/min, which exceeds the specified 2 L/min of oxygen.
D: 36% FiO2. This percentage indicates an even greater flow rate, usually around 4 L/min, making it unsuitable for the 2 L/min provided in this scenario.
The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
Rationale:
Chest pain and anxiety indicate an air embolus during hemodialysis, as these symptoms suggest a sudden issue affecting cardiovascular stability and oxygenation, aligning with the physiological responses to an embolism.
A: cold intolerance This symptom does not specifically relate to an air embolus, as it typically pertains to temperature regulation issues rather than cardiovascular or respiratory complications during hemodialysis.
C: decreased respirations While decreased respirations can indicate respiratory distress, it lacks the specificity to air embolism symptoms, which more directly involve chest pain and anxiety relating to vascular compromise.
D: hypertension and widening pulse pressure These findings suggest different cardiovascular issues rather than air embolism, which typically presents more acutely with symptoms such as chest pain and anxiety, reflecting immediate distress.
The nurse is caring for a client who has been diagnosed with pulseless electrical activity (PEA). Following effective CPR and administration of epinephrine, which is the next priority nursing action?
Rationale:
Check for a pulse.
Following effective CPR and epinephrine administration, assessing for a pulse is critical to determine the effectiveness of resuscitation efforts and guide further interventions for the client's condition.
B: Insert a urinary catheter. This action does not address immediate cardiac function, and ensuring circulation is more crucial than managing urinary output in the context of PEA.
C: Prepare to shock the client. Shock is inappropriate in pulseless electrical activity without a pulse; the first step must be assessing circulation before considering defibrillation.
D: Administer a bolus of sodium bicarbonate. This intervention is not a priority during PEA; confirming the presence of a pulse takes precedence to guide subsequent treatment measures.
The nurse is caring for a client in the ICU who has an arterial line for hemodynamic monitoring. Which action will the nurse take in caring for this client?
Rationale:
Position the client with the transducer at the level of the right atrium. This positioning is essential for accurate hemodynamic monitoring, as it allows for proper reference to the heart’s central venous pressure, ensuring reliable readings that guide treatment decisions in critical care settings.
B: position the client with the transducer at the level of the left ventricle. This placement does not provide accurate measurements for hemodynamic monitoring, leading to potential misinterpretations of the patient’s cardiovascular status.
C: position the client with the transducer at the level of the right clavicle. This location is too high and does not reflect the true hemodynamic pressures necessary for accurate monitoring of the client’s condition.
D: position the client with the transducer at the level of the right ventricle. This positioning is inappropriate for central venous pressure readings and can result in inaccurate hemodynamic assessments, compromising patient care.
The nurse is assessing a client with Graves' disease. Which assessment finding would the nurse expect in this client?
Rationale:
Exophthalmos. This manifestation occurs due to the overactivity of the thyroid gland in Graves' disease, leading to inflammation and swelling behind the eyes, resulting in a characteristic protrusion of the eyeballs.
A: bradycardia This choice contradicts the typical symptoms of Graves' disease, which often include tachycardia or increased heart rate, rather than a slowed heartbeat.
B: constipation Individuals with Graves' disease typically experience diarrhea or increased bowel movements rather than constipation, which is more common in conditions of hypothyroidism.
D: recent weight gain Hyperthyroidism, as seen in Graves' disease, commonly results in weight loss due to increased metabolism, making weight gain an unlikely symptom for this condition.
The nurse notes irritability, microcephaly, and short palpebral fissures in a newborn in the nursery. The nurse suspects which diagnosis for this infant?
Rationale:
Fetal alcohol syndrome (FAS) is suspected in this infant due to the combination of irritability, microcephaly, and short palpebral fissures, which are characteristic features associated with prenatal alcohol exposure.
A: syphilis Severe infections like syphilis can affect newborns, but they typically present with different symptoms such as skin rashes or hepatosplenomegaly, not the specific features noted here.
B: TORCH syndrome This term encompasses a range of infections affecting newborns, yet the specific signs of irritability and microcephaly align more closely with fetal alcohol exposure than with typical TORCH presentations.
C: brachial plexus injury This condition involves nerve damage during delivery, leading to weakness or paralysis in the arm and does not correlate with the neurological and craniofacial features observed in this infant.
The nurse is caring for a client who is HIV positive and gave birth to a full-term infant. The nurse is teaching the client about infections in HIV-positive infants. Which infection does the nurse understand is the most common opportunistic infection in children and infants with HIV?
Rationale:
Pneumocystis jiroveci pneumonia is the most common opportunistic infection in children and infants with HIV. This infection significantly affects immunocompromised individuals, particularly those with HIV, due to their weakened immune systems, making them more susceptible to respiratory infections.
A: hepatitis C This viral infection primarily affects the liver and is not classified as an opportunistic infection associated with HIV in infants.
B: strep throat This bacterial infection is common in healthy individuals and does not specifically relate to opportunistic infections in children with HIV.
C: cytomegalovirus infection Although significant, cytomegalovirus is less prevalent than Pneumocystis jiroveci pneumonia as an opportunistic infection in infants with HIV.
The nurse is caring for a client who had a basilar artery stroke. The nurse would expect which signs and symptoms in this client?
Rationale:
Impaired consciousness, visual loss, bilateral sensory and motor dysfunction, and pupil abnormalities are expected signs and symptoms after a basilar artery stroke, which affects brainstem functions and visual pathways.
A: Memory problems, visual hallucinations, visual deficits, hemisensory disturbances. Although visual deficits are relevant, this option lacks the critical signs of impaired consciousness and bilateral dysfunction specific to a basilar artery stroke.
B: Weakness in the foot and leg, sensory loss in the foot and leg, incontinence, ataxia, lack of spontaneity. This choice describes lower limb issues and does not encompass the full spectrum of neurological impairment associated with a basilar artery event.
D: Ataxia, contralateral facial weakness, contralateral hemiplegia, visual deficits, speech impairments, perceptual impairments. While this option includes relevant symptoms, it primarily focuses on unilateral effects rather than the bilateral dysfunction characteristic of a basilar artery stroke.
The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention?
Rationale:
D: Complaints of sudden and severe back pain and shortness of breath indicate a potential rupture or serious complication of the abdominal aortic aneurysm, necessitating immediate medical intervention to prevent life-threatening consequences.
A: Complaints of yellow-tinted vision suggest possible liver dysfunction or medication side effects, which, while concerning, do not indicate an acute emergency related to the aneurysm.
B: Sudden onset of frothy, pink sputum points to pulmonary edema or heart failure, conditions that require attention but are not directly linked to the immediate risks of an abdominal aortic aneurysm.
C: Urinary output of 75 mL/hr. per urinary catheter is within normal limits, indicating adequate renal function, and does not represent an urgent issue in the context of an abdominal aortic aneurysm.
The nurse is caring for a client experiencing an acute flare-up of diverticular disease. Which interventions by the nurse are appropriate for this client? Select all that apply.
Rationale:
D: administer IV fluids as ordered, F: check stools for frank or occult bleeding. Administering IV fluids maintains hydration and electrolyte balance during flare-ups, while monitoring stools helps identify potential complications like bleeding, crucial for effective management.
A: encourage a diet high in fiber. High-fiber diets are typically recommended for diverticular disease management but may exacerbate symptoms during acute flare-ups, making this intervention unsuitable.
B: insert a nasogastric (NG) tube. Inserting an NG tube is typically reserved for severe cases where bowel rest is necessary, which does not apply in all acute flare-ups of diverticular disease.
C: administer enemas as ordered. Enemas can irritate the colon and are generally contraindicated during acute diverticulitis, as they may worsen inflammation and lead to complications.
E: encourage coughing and deep breathing. While important in many contexts, these actions are not specifically relevant to managing diverticulitis flare-ups and may cause discomfort in an already sensitive abdominal area.
The nurse is precepting a student nurse. The primary nurse asks the student nurse to figure the client's intake and output for the shift. Which statement by the student nurse indicates an understanding of this procedure?
Rationale:
D: I will include all IV fluids, liquids the client drank, IV flushes, and IV antibiotics in my intake total. This statement demonstrates a comprehensive understanding of intake measurement, recognizing that all sources of fluid intake contribute to the total calculation, which is essential for accurate client assessment.
A: Wound drainage is not included in output measurement. This statement overlooks that wound drainage can significantly impact fluid balance and should be included in output calculations for accurate assessments.
B: I only need to count urinary output for my output total. This statement neglects other important sources of output such as stool, emesis, and drainage, which are crucial for a complete assessment.
C: I don't need to count the client's emesis since it was a small amount. This viewpoint disregards the importance of tracking all emesis, regardless of volume, as it can affect the client’s fluid balance.
The nurse comes upon a client in the clinic who appears to have experienced a sudden cardiac arrest. After retrieving the automated external defibrillator (AED), the nurse knows to use the equipment in the following manner, as per the American Red Cross. List the steps in order. Use all the steps.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Make sure no one is touching the client. Tell everyone to 'stand clear.'
B
Open the person's shirt and wipe the chest dry. Remove any visible patches.
C
Attach the AED pads and plug in the connector.
D
Push the 'analyze' button to analyze the client's heart rhythm.
E
Turn on AED. Follow visual and/or audio prompts.
F
Begin CPR.
G
As prompted, press the 'shock' button after clearing the client.
Rationale:
Turn on AED. Follow visual and/or audio prompts. This initial step is crucial for guiding the user through the subsequent actions necessary for effective defibrillation and managing the situation appropriately.
A: Make sure no one is touching the client. Tell everyone to 'stand clear.' This step is vital but must occur after the AED is turned on for safety.
F: Begin CPR. While CPR is essential, it should follow the AED activation for optimal timing and rhythm analysis.
G: As prompted, press the 'shock' button after clearing the client. This action is contingent upon prior steps being completed correctly, particularly the analysis.
Which nursing action is most appropriate to initially relieve pain related to a recent soft tissue injury?
Rationale:
Applying an ice pack is the most appropriate initial action to relieve pain related to a recent soft tissue injury. Cold therapy reduces inflammation and numbs the area, providing immediate pain relief.
A: administer an over-the-counter (OTC) medication for pain. While OTC medications can alleviate pain, they do not address inflammation as effectively as ice, which is crucial for recent injuries.
B: apply heat. Heat can exacerbate inflammation and swelling in the first stages of a soft tissue injury, potentially worsening the pain rather than providing relief.
C: massage the area. Massaging a recent injury may increase irritation and inflammation, leading to heightened discomfort and potentially causing further damage to the affected tissue.
A client is brought to the ED following a drowning event. The nurse assigned to the client understands that which is true regarding drowning?
Rationale:
If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment. Understanding the underlying cause aids in effective management and potential interventions, ensuring comprehensive care and addressing any pre-existing medical issues that may have contributed to the drowning event.
A: Drowning in very cold water causes a worse outcome for the client than drowning in warmer water. The severity of outcomes can vary significantly based on multiple factors, not solely water temperature.
B: Aspiration of both salt and fresh water increases surfactant in the lungs and leads to increased lung compliance. This misconception overlooks the detrimental effects of aspirating water, which can impair lung function rather than enhance it.
D: Contaminants in the water such as microbes, mud, chemicals, and algae do not affect the degree of injury to the lungs. In reality, these contaminants can exacerbate lung injury and complicate recovery, impacting overall health outcomes.
The nurse is caring for a client who had an inguinal hernia repair. Which interventions by the nurse are appropriate for this client? Select all that apply.
Rationale:
Encouraging fluid intake, relieving urinary retention, teaching turning, coughing, and deep breathing, and instructing the client to avoid lifting more than 20 pounds until approved by the health care provider are appropriate interventions.
Encouraging adequate hydration supports recovery by preventing complications such as dehydration and urinary issues. Relieving urinary retention ensures comfort and reduces the risk of infection.
C: Applying heat to the scrotum may exacerbate swelling and discomfort post-surgery, leading to potential complications.
E: Keeping the client on bed rest for the first 12 hours can delay recovery and hinder mobility, which is essential for healing.
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
Rationale:
The client should be in semi-Fowler's with the affected arm supported on a pillow. This position promotes comfort, reduces strain on the surgical site, and facilitates drainage, enhancing recovery post-mastectomy.
A: high Fowler's with the unaffected arm elevated on a pillow. This position may increase discomfort for the client and does not adequately support the affected side after surgery.
B: flat with the client positioned on the affected side or back. Lying flat on the affected side could cause unnecessary pressure and discomfort, hindering recovery and drainage.
D: reverse Trendelenburg's with the arm on the affected side supported on a pillow. This position may not provide adequate support for the surgical area and can compromise comfort in the post-operative phase.
The nurse is teaching a newly diagnosed client about Guillain-Barré syndrome (GBS). What information would the nurse provide in her teaching? Select all that apply.
Rationale:
Guillain-Barré syndrome tends to be self-limiting with temporary paralysis, common symptoms include muscle weakness and paralysis, and infections such as Epstein-Barr virus have been associated with GBS.
A: GBS affects females more often than males. Epidemiological studies indicate no significant gender preference, as GBS affects both genders equally, thereby making this statement misleading.
B: The acute period lasts several days to 2 weeks. The acute phase of GBS can vary in duration, often extending beyond two weeks depending on individual circumstances and progression of symptoms.
The nurse is caring for a client who has shortness of breath, +2 pitting edema bilaterally of the lower extremities, crackles in the bases of the lungs, and a weight gain of 7 pounds in 1 week. The nurse administers furosemide 40 mg IV as ordered. Which would the nurse anticipate to indicate that the furosemide was effective? Select all that apply.
Rationale:
B: Pitting edema of +1 indicates a reduction in fluid retention, suggesting the furosemide is effectively removing excess fluids. This aligns with the desired therapeutic effect of the medication.
A: Pitting edema of +3 shows worsening fluid retention, countering the expected outcome of furosemide, which aims to reduce edema and fluid overload in the patient.
B: Less shortness of breath reflects improved lung function and decreased pulmonary congestion, indicating successful diuresis and a positive response to furosemide treatment.
C: An increase in urine output of 250 mL/hr signifies effective diuresis, demonstrating that furosemide is promoting renal excretion of excess fluid, a primary goal of therapy.
D: A decrease or absence of crackles in the lungs suggests improved pulmonary status, as it reflects reduced fluid in the alveoli, indicating effective diuretic action from furosemide.
The nurse is seeing a client in the clinic who complains of a sore throat. The client asks for an antibiotic. How should the nurse respond? Select all that apply.
Rationale:
You can try gargling with warm saline to relieve the discomfort, most sore throats are caused by viruses, which cannot be treated with antibiotics, and you should increase your fluid intake.
A: Gargling with warm saline offers soothing relief and can help alleviate throat irritation effectively without the need for medication.
B: Using a dehumidifier does not directly address throat discomfort and could potentially lead to throat dryness rather than providing relief.
D: While there are antibiotics for bacterial infections, most sore throats arise from viral causes, making antibiotics unnecessary and inappropriate.
The oncology nurse is assessing a client diagnosed with cancer of the tongue. Upon examination, which signs and symptoms would the nurse expect to find? Select all that apply.
Rationale:
D: difficulty swallowing, E: a sore that bleeds or does not heal, F: difficulty chewing or pain with chewing. These signs and symptoms are common in tongue cancer due to tumor presence, tissue damage, and potential obstruction affecting normal oral functions, particularly swallowing and chewing, while also indicating wound healing issues from the malignancy.
A: weight gain. Cancer of the tongue typically leads to weight loss due to difficulty eating and swallowing rather than weight gain, which is not a common symptom.
B: well-fitting dentures. Individuals with tongue cancer often experience oral pain and changes in oral structures, making well-fitting dentures unlikely as a relevant symptom in this context.
C: a black, hairy tongue. This condition is unrelated to tongue cancer and generally results from poor oral hygiene or certain medications, not indicative of malignancy in the tongue.
The nurse is assessing a client with Parkinson's disease. Which sign of primary motor symptom involvement would the nurse expect to observe?
Rationale:
Resting tremor. This symptom is a hallmark of Parkinson's disease, characterized by involuntary shaking that typically occurs when the muscles are at rest. It significantly impacts motor function and is commonly observed in affected individuals.
B: Sleep disturbance. While sleep issues can arise in Parkinson's disease, they are secondary effects and not a primary motor symptom, making them less directly associated with the condition's hallmark signs.
C: Constipation. Although gastrointestinal issues like constipation may occur in those with Parkinson's, they are not primary motor symptoms. Instead, they stem from autonomic nervous system dysfunction.
D: Fatigue. Fatigue can be prevalent among Parkinson's patients, yet it is not a primary motor symptom. It often results from other factors, including medication side effects and overall disease progression.
A nurse is employed on an oncology unit. A 62-year-old client is admitted for surgical treatment of a meningioma. The nurse would anticipate modifying the environment for which symptom?
Rationale:
B: The nurse would anticipate modifying the environment for seizures, as meningiomas can lead to neurological disturbances, including seizure activity. Creating a safe environment is essential to prevent injury during seizure episodes.
A: difficulty swallowing This symptom is not typically associated with meningiomas, as they primarily affect seizure activity and cognitive functions rather than swallowing capabilities, making this option less relevant.
C: poor concentration While cognitive effects may arise, the most pressing environmental modification revolves around seizure precautions rather than concentration, which is often secondary to other symptoms.
D: impaired mobility Meningiomas primarily influence neurological function, but impaired mobility is not a direct consequence typically requiring environmental modifications, thus making this option less critical for the nursing intervention.
The nurse is preparing to administer cefazolin to a client who is allergic to penicillin. The client states that penicillin causes him to itch and be slightly short of breath. Which response by the nurse is correct?
Rationale:
C: Hold the medication and notify the health care provider. This response prioritizes patient safety by acknowledging the client's allergy to penicillin, which may indicate a risk of cross-reactivity with cefazolin, prompting further evaluation.
A: administer the cefazolin as ordered. Ignoring the client's allergy to penicillin could lead to an adverse reaction, compromising the patient's safety and well-being during treatment.
B: call the pharmacy to substitute another medication. This option does not address immediate concerns about the client's allergic reaction and could delay necessary medical intervention for potential complications.
D: give the client diphenhydramine and then administer the cefazolin. Administering diphenhydramine does not eliminate the risk of an allergic reaction and could mask symptoms, putting the client at risk.
The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position?
Rationale:
B: semi-Fowler's positioning aids in reducing intraocular pressure, which is crucial for a patient with hyphema. This position promotes comfort and minimizes the risk of further bleeding or complications associated with the injury.
A: flat in bed does not provide the necessary elevation to manage intraocular pressure effectively, potentially worsening the patient's condition.
C: Trendelenburg's position could increase pressure on the eyes, exacerbating the hyphema and leading to further complications.
D: lateral on the unaffected side may not adequately address the specific needs of a patient with hyphema, as it does not help in controlling intraocular pressure.
Which of the following is not a recommended preparation for electroconvulsive therapy (ECT)?
Rationale:
Electroconvulsive therapy (ECT) does not typically require the administration of an anticonvulsant 30 minutes before the procedure. ECT is designed to induce controlled seizures, thus anticonvulsants may counteract its intended effects.
A: premedication with an anticholinergic agent This preparation is often recommended to reduce secretions and minimize potential complications during ECT, enhancing patient comfort and safety throughout the procedure.
B: morning bath, NPO after midnight Maintaining NPO status after midnight prevents aspiration during anesthesia, while a morning bath can promote hygiene and relaxation, both important for a successful ECT session.
C: informed consent in writing Written informed consent is essential to ensure that patients understand the procedure, its risks, and benefits, thus respecting their autonomy and legal rights before undergoing ECT.
The nurse is preparing to extubate a client. Arrange in order of priority the actions that the nurse should take to perform this procedure.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
hyperoxygenate the client
B
explain the procedure to the client
C
immediately instruct the client to cough
D
apply oxygen by nasal cannula or face mask
E
thoroughly suction the ET tube and the oral cavity
F
teach the client how to use an incentive spirometer every 2 hours
G
set up oxygen/emergency equipment
Rationale:
B: Explaining the procedure to the client is essential to ensure they understand what to expect during extubation, alleviating anxiety and promoting cooperation during the process.
A: Hyperoxygenating the client does not address the immediate need for patient understanding and preparation, which is critical before performing the procedure.
C: Instructing the client to cough should occur after extubation, not immediately. Prioritizing patient education and comfort is crucial beforehand.
D: Applying oxygen via nasal cannula or face mask is necessary post-extubation but follows the need for explanation and preparation to ensure a smooth transition.
E: Thoroughly suctioning the ET tube and oral cavity is important for clearing secretions but should follow patient education to ensure the client is ready for the procedure.
F: Teaching the use of an incentive spirometer is beneficial post-extubation but does not take precedence over informing the client about the procedure and ensuring their readiness.
G: Setting up oxygen/emergency equipment is vital but comes after ensuring the client understands the procedure, as preparation and patient reassurance are primary concerns.
Which assessment finding in a client with chronic kidney disease indicates late-stage symptoms?
Rationale:
Oliguria indicates late-stage symptoms in a client with chronic kidney disease, reflecting a significant decrease in urine output. This condition signifies advanced renal impairment, often leading to fluid overload and further complications associated with kidney failure.
A: Shortness of breath signifies fluid overload or respiratory issues, but it is not exclusively indicative of late-stage chronic kidney disease. Various conditions can cause this symptom.
C: Tea-colored urine may suggest hematuria or dehydration, but it does not specifically indicate late-stage chronic kidney disease. It can occur in various other conditions.
D: Edema in lower extremities can occur at various stages of kidney disease and is not uniquely indicative of late-stage symptoms, as it may arise from numerous other factors.
A student nurse is precepting on the cardiac unit with the charge nurse. The charge nurse is educating the student about heart sounds and asks the student nurse to describe what causes the S1 sound. Which response by the student nurse reflects an understanding of cardiac sounds?
Rationale:
It is caused by the mitral and tricuspid valves closing. The S1 heart sound is generated when the ventricles contract, leading to the closure of the mitral and tricuspid valves, marking the beginning of systole. This sound is crucial for assessing cardiac function and indicates effective valve operation.
B: It is caused by the mitral and pulmonic valves closing. This response misidentifies the valves involved in producing the S1 sound, as the pulmonic valve closure occurs later during systole.
C: It is caused by the pulmonic and aortic valves closing. This option incorrectly describes the S1 sound, as it pertains to the closure of the aortic and pulmonic valves, which relate to S2.
D: It is caused by the aortic and tricuspid valves closing. This statement erroneously attributes the S1 sound to the aortic valve, which actually contributes to the S2 sound, not S1.
The nurse is caring for a client in ICU diagnosed with rabies following a bite from an infected raccoon. The nurse understands which to be true regarding rabies? Select all that apply.
Rationale:
The client should not be bathed, and no running water should be present within hearing of the client. Rabies can cause extreme anxiety and phobic reactions, making exposure to water distressing and potentially life-threatening. Therefore, maintaining a calm environment without water sounds is crucial for the client's well-being during treatment and care.
B: Current treatment includes two doses of immunoglobulin and six doses of rabies vaccine over a period of 21 days. Rabies treatment actually involves post-exposure prophylaxis that includes a specific regimen of vaccines and immunoglobulin, differing from this statement's dosage and schedule.
E: During the neurological phase, the client may have aches and pains in different parts of the body, along with sensitivity to light. While neurological symptoms occur, the primary manifestations focus on severe agitation, confusion, and other more critical neurological signs, not just generalized aches.
A nurse is providing pre-op teaching to a client who will be undergoing a coronary artery bypass graft. Which of the following should the nurse include in the teaching? Select all that apply.
Rationale:
Your medications will be changed after surgery, you will need to splint the chest incision when you cough or breathe deeply, and you will be on the ventilator after surgery and have one or more chest tubes.
A: Your medications will be changed after surgery. Post-operative medication adjustments are common to manage pain and prevent complications, making this information crucial for the patient’s recovery process.
D: You will need to splint the chest incision when you cough or breathe deeply. Proper incision support is essential to minimize pain and prevent strain, which aids in effective healing.
E: You will be on the ventilator after surgery and have one or more chest tubes. While some patients may require a ventilator or chest tubes, not all will need them, making this information not universally applicable.
B: You will be on strict bed rest for the first 48 hours. While limited activity is advised, complete bed rest is not typically necessary and can hinder recovery and mobility.
C: You will be using a bedpan after surgery to urinate. Many patients are encouraged to use the bathroom rather than a bedpan to promote mobility and faster recovery, making this statement misleading.
The nurse is reviewing labs on a client with second- and third-degree burns from a house fire. Which abnormal lab value would the nurse expect to find with this client?
Rationale:
Elevated potassium levels of 5.9 mEq/L are expected in clients with significant burns due to cell damage and tissue destruction, which release potassium into the bloodstream, causing hyperkalemia.
A: pH of 7.41 Normal arterial blood pH indicates no acidosis or alkalosis, which would typically be affected by significant burns and thus does not align with the expected lab findings.
B: albumin of 3.9 g/dL This value reflects normal serum albumin levels; in burn patients, decreased albumin is common due to fluid shifts and protein loss from damaged tissues.
C: hemoglobin of 15 g/dL This normal hemoglobin level suggests adequate oxygen-carrying capacity, whereas burn patients often experience anemia or fluid shifts affecting hemoglobin concentration.
The nurse is precepting a student nurse on leukemia classifications. Which statement by the student nurse reflects an understanding of classifications of leukemia?
Rationale:
Acute myelogenous leukemia has primarily granulocytes present in the bone marrow. This statement accurately reflects the characteristic proliferation of myeloid cells in acute myelogenous leukemia, where granulocytes dominate the marrow, distinguishing it from other leukemia types.
A: Acute lymphocytic leukemia has an average age of onset of 15 to 39 years. This range is inaccurate, as acute lymphocytic leukemia typically presents in younger populations, especially children.
C: Chronic myelogenous leukemia has mostly lymphocytes found in the bone marrow. This classification is incorrect; chronic myelogenous leukemia is characterized by an increase in myeloid cells, particularly granulocytes, not lymphocytes.
D: Acute myelogenous leukemia has primarily granulocytes present in the bone marrow. This option misidentifies the cell type and does not accurately reflect the myelogenous nature of the disease's classification.
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
Rationale:
Hypotension; weak pulse; cool, clammy skin are expected signs in a client with cardiogenic shock. These symptoms indicate inadequate cardiac output and poor perfusion, common in this critical condition.
A: hypertension; slow, labored breathing. Hypertension is not typically associated with cardiogenic shock, where blood pressure usually drops due to the heart's inability to pump effectively.
B: decreased urine output; warm, pink skin. While decreased urine output is expected, warm, pink skin contradicts the typical presentation of cool, clammy skin seen in inadequate perfusion.
C: increased urine output; cool, clammy skin. Increased urine output does not align with cardiogenic shock, where renal perfusion decreases, leading to lower urine production despite the presence of cool, clammy skin.