A nurse is assigned to care for an anxious client who has an open pneumothorax and sucking chest wound. An occlusive dressing has been applied to the site. Which of the following action of the nurse would best relieve the client’s anxiety?
a. Stay with the client as necessary
b. Interpreting the arterial blood gas report
c. Encouraging the client to cough and deep breath
d. Distracting the client with television
RATIONALE: Staying with the client has a two-fold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after application of the occlusive dressing.
A female client is to have arterial blood gases drawn. While the nurse is performing the Allen test, the client asks the nurse about the significance of the test and what procedure she is doing because no one else has done the same procedure before. The nurse makes which therapeutic response to the client.
a. “ I assure you that I am doing the correct procedure, I cannot account for what others do”
b. “This is a routine precautionary step that simply makes certain circulation is intact before obtaining a blood sample”
c. Oh? “You have questions about this? You should insist that they all do this procedure before drawing up your blood”
d. This step is crucial to safe blood withdrawal, I would not let anyone take my blood until they do this”
RATIONALE: The Allen test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response provides information to the client.
A physician scheduled a male client for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure/
a. Allergy to iodine
b. Vital signs
c. Height and weight
d. Intake and output
RATIONALE: The procedure involves the injection of radiopaque dye into the blood vessel. If the client has allergy to iodine the procedure will not be advised to prevent complications of the client’s reaction to the dye.
A nurse has given medication instruction to client who is receiving furosemide (lasix). The nurse determines that the client needs further instructions if the client states that:
a. ”I need to talk to my physician about the use of alcohol”
b. “I need to avoid the use of salt substitutes because they contain potassium”
c. “I need to be careful not to get overheated in warm weather”
d. “I need to change positions slowly”
RATIONALE: Furosemide is a potassium-losing diuretic, so there is no need to avoid high-potassium product such as a salt substitute. Orthostatic hypotension is a risk. And the client must caution with changing position and with exposure to warm weather. The client needs to discuss the use of alcohol with the physician.
A nurse is assisting in planning care to a newly admitted client. On entering the room of the client, the nurse notes that the client’s legs are elevated, the trunk is position flat and the head and shoulder are slightly elevated. The position of the client is appropriate for prevention of:
a. Increased Intracranial Pressure
c. A head injury
d. Respiratory insufficiency
RATIONALE: A client in shock is placed in a modified Trendelenburg position that includes elevating the legs, leaving the trunk flat and elevated head and shoulders. This position promotes increase venous return from the lower extremities without compressing the abdominal organ against the diaphragm.
A nurse is caring for a 12-year old client with chest pain. As she is making her rounds, she enters the room of her client and finds that the toy is on fire. The nurse immediately assists the client to get out of the room. What would be the next nursing action in this event?
a. activate the fire alarm
b. call for help
c. extinguish the fire
d. Confine the fire by closing the door of the room
RATIONALE: The order of priority in the event of fire is to rescue the clients who are in immediate danger. The next step is to activate the alarm. The fire then is confided by closing the door and last the fire is extinguished.
A nurse has just finished suctioning the tracheostomy of a female client. The nurse plans to monitor the effectiveness of the procedure of which of the following item?
a. respiratory rate
b. oxygen saturation level
c. capillary refill
d. breath sound
RATIONALE: After suctioning, client either with or without artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds.
A nurse is monitoring the status of a client with chest tube. The chest tube is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal chamber is less than 2cm mark. The nurse determines that:
a. water should be added to the chamber
b. there is leak in the system
c. suction should be added to the system
d. this is caused by client pneumothorax
RATIONALE: The water seal chamber should be filled to the 2cm mark to provide an adequate water seal between the external environment and the client’s pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should solve this problem by adding water until the level is gain at the 2cm mark.
A client is admitted to a surgical unit postoperatively with a wound drain in place. A nurse assesses the client’s surgical incision for sign of infection. Which finding by the nurse would be interpreted as s normal finding at the surgical site?
a. red, hard skin
b. purulent drainage
c. serous drainage
d. warm, tender skin
RATIONALE: Serous drainage is an expected finding at a surgical site. The other options indicate sign of wound infection.
A nurse in a surgical unit receives a postoperative client form the post anesthesia care unit. After the initial assessment of the client, the nurse plans to monitor and continue with post operative assessment activities. Which of the following would be appropriate?
a. every 15minutes for the first hour, every 30minutes for the second hour, every hour for 4 hours and then every four hour as needed.
b. every 5minutes for the first half hour, every 15 minutes for two hours, every 30minutes for four hours and then every hour as needed
c. every 30minutes for the first hour, every hour for two hours, then every four hours as needed
d. every hour for two hours, then every four hours as needed
RATIONALE: When the post operative client arrives from the post anesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes for the first hour, every 30 minutes for the second hour, and then every hour for four hours and every four hour as needed.