Question 1

The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease.  Which statement indicates that further teaching is needed?

Accepted Answer

Clients with chronic kidney disease (CKD) are at risk for fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia (Option B). To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option A). Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice (Option C). Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg, popsicles, gelatin), because fluid is often restricted (Option D). Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein intake is recommended to prevent malnutrition. Low-phosphorus diet - Avoid foods high in phosphorus (eg, chicken, turkey, dairy). Educational objective: Clients with chronic kidney disease are at risk for fluid overload and hyperkalemia. An appropriate renal diet includes low sodium, low potassium, low phosphorus, and low protein.

Question 2

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

Accepted Answer

11ecbb05_ca75_effb_b433_09df97ed08a8_MD0009_00 Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. (Option A) Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. (Option B) Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95%-100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. (Option C) The anesthesia professional may need to be informed, but methods to restore the oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent. Educational objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway.

Question 3

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

Accepted Answer

Acute respiratory failure (ARF) is a life-threatening impairment of the lungs' ability to oxygenate blood and excrete carbon dioxide (CO₂). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses. Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO₂(Option D). Additional signs and symptoms may include paresthesias, dyspnea, tachypnea, and hypoxemia. (Option A) Clients recovering from recent pneumonectomy (ie, surgical removal of part or all of the lung) often experience considerable pain, which may cause respiratory distress if not adequately controlled. A client with tachypnea and severe pain should be seen promptly but only after addressing potential ARF. (Option B) Crackles, absent or diminished breath sounds over the affected lobe, and slightly decreased oxygen saturation are expected findings in pleural effusion, in which fluid collects in the space surrounding the lung. (Option C) Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe. Educational objective: Acute respiratory failure is a life-threatening impairment of lung function that inhibits gas exchange. Common symptoms include altered mental status (eg, confusion, agitation, somnolence), paresthesias, dyspnea, tachypnea, and hypoxemia, all of which should be addressed immediately.

Question 4

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action?

Accepted Answer

11ecbb05_ca74_b779_b433_d1ce0ac6472b_MD0009_00 Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep. In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary (Option B). (Option A) Underlying OSA is the most likely reason for this client's drop in oxygen saturation during sleep. If CPAP is not effective, then the characteristic OSA signs (eg, hypoxia, hypercapnia) will occur. In addition, decreased level of consciousness and lung sounds are expected when there is no airflow to the lungs. Although the nurse should assess these parameters, this should not be the first action. (Option C) If the attempt to readjust the straps and mask seal does not reverse the client's hypoxemia quickly, the nurse should notify the health care provider and respiratory therapist (per institution policy). However, this should not be the nurse's first action. (Option D) Supplemental oxygen may be indicated if readjustment of the straps and mask seal does not reverse the client's hypoxemia quickly. This should not be the nurse's first action. Educational objective: CPAP is prescribed for clients with obstructive sleep apnea in the home and clinical settings. The mask is secured with adjustable head straps to maintain a snug fit over the face to prevent air leakage and loss of positive pressure.

Question 5

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first?

Accepted Answer

11ecbb05_ca77_9dad_b433_15e1e7c6976f_MD0009_00 Peritonsillar, or retropharyngeal, abscess is a serious complication that can result from tonsillitis or pharyngitis. The presenting features of peritonsillar abscess, in addition to fever, include a "hot potato" (muffled) voice, trismus (inability to open the mouth), pooling of saliva (drooling), and deviation of the uvula to one side. The abscess can progress to life-threatening airway obstruction (eg, dysphagia, stridor, restlessness). The nurse should immediately assess the client with symptoms of peritonsillar abscess and monitor for signs of airway obstruction (Option C). (Option A) A client with epistaxis (ie, nosebleed) that does not resolve with external pressure will require further hemostatic interventions, such as cauterization or nasal packing (eg, gauze, nasal tampon, balloon catheter). This client should be assessed after the client with signs of impending airway obstruction. (Option B) Symptoms of acute sinusitis include severe facial pain, nasal congestion with purulent nasal drainage, and fever. In most cases, the etiology is viral but can be complicated by secondary bacterial infection. This client likely requires antibiotics and supportive care but is not the priority. (Option D) Acute otitis media (ie, infection of the middle ear) may develop secondary to rhinitis (eg, common cold, seasonal allergies) due to inflammation of the Eustachian tube. This client with otitis media will likely require antibiotics and pain management but is not the priority. Educational objective: Peritonsillar abscess is an emergent complication of tonsillitis that can lead to life-threatening airway obstruction. Symptoms of peritonsillar abscess include fever, trismus (inability to open the mouth), drooling, muffled voice, and deviation of uvula to one side.

Question 6

After receiving a change-of-shift report, the nurse should assess which client first?

Accepted Answer

The client who just underwent a bronchoscopy is at risk for becoming unstable. During a bronchoscopy, the larynx, trachea, and bronchi are visualized using an endoscope while the client is under sedation. Respiratory status, airway patency, vital signs, and sedation level should be assessed immediately upon return from the procedure and at regular intervals until the client becomes stable. The client must be kept NPO until alert with a positive gag reflex. (Option A) Clients with a positive tuberculin skin test and hemoptysis may have tuberculosis. They will need a chest x-ray and sputum culture to confirm the diagnosis and may be initiated on an antitubercular medication regimen. However, this client does not require immediate attention. (Option B) The nurse should address any factors that may cause a client to refuse incentive spirometry (eg, pain). This client may require education on the importance of incentive spirometry (eg, prevention of atelectasis and pneumonia) or administration of PRN analgesics to encourage participation in deep-breathing exercises. However, this client does not require immediate attention. (Option D) Air bubbles in the suction control chamber of a chest tube drainage system would be a normal finding. Air bubbles in the water seal chamber may indicate a leak and would require immediate intervention. Educational objective: Clients returning from procedures performed under sedation should receive priority assessment of vital signs and respiratory status.

Question 7

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply.

Accepted Answer

11ecbb05_ca78_d62f_b433_4fa4cb520bec_MD0009_00 Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO₃- (<22 mEq [22 mmol/L]). Common causes of metabolic acidosis include: GI bicarbonate losses (eg, diarrhea) (Option B) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) (Option D) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option E) Salicylate toxicity (Option A) A client with claustrophobia who was stuck in an elevator is at risk for an anxiety attack, which leads to hyperventilation and respiratory alkalosis (pH >7.45, PaCO2 <35 mm Hg [4.66 kPa]). (Option C) A client with excessive vomiting is at risk for metabolic alkalosis due to loss of stomach acid. Educational objective: Conditions that increase acid production or retention (eg, ketoacidosis, lactic acidosis, renal failure) or bicarbonate depletion (eg, diarrhea) can put a client at risk for metabolic acidosis (pH <7.35, HCO₃- <22 mEq/L [22 mmol/L]).

Question 8

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?

Accepted Answer

Catheter-associated urinary tract infections are prevalent in hospital settings. Only indwelling urinary catheters should be used when appropriate. Appropriate uses include the following: Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clientsPerioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgeryDuring prolonged immobilization when bedrest is essentialTo improve end-of-life comfortTo facilitate healing of an open perineal or sacral wound in incontinent clients Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bedrest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include the following: Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options B, C, and D)For obtaining a urine culture when the client can follow instructions and void voluntarilyPostoperatively for prolonged periods when other appropriate indications are not present Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently (Options B, C, and D) For obtaining a urine culture when the client can follow instructions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present Educational objective: The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care.

Question 9

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply.

Accepted Answer

Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs (Option D). The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight (Option C). After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary (Option A). (Option B) During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). (Option E) Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly. Educational objective: The nurse is responsible for assessing the client diagnosed with end-stage renal disease for risks associated with dialysis. These risks include medication removal, hemodialysis access dysfunction, hypotension, and fluid and electrolyte imbalances.

Question 10

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action?

Accepted Answer

11ecbb05_ca75_a1da_b433_77c6d943bfde_MD0009_00 The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT. (Option A) The client's restlessness and confusion are likely secondary to low oxygenation. Anxiety will cause hyperventilation, which will only exacerbate the situation. However, administering anti-anxiety medication is not the priority over obtaining help quickly. In addition, the client's oxygenation could deteriorate depending on the prescribed anti-anxiety medication, which could depress respirations. (Option B) The health care provider who performed the surgery must be notified of the client's deteriorating condition; however, this should be done after calling the RRT. Stabilizing the client is the priority. (Option D) The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed. This position maintains the airway and ensures that the client does not choke on vomit. Educational objective: When a client is demonstrating clinical deterioration, the nurse's priority is to prevent full respiratory or cardiac arrest by calling the rapid response team.

Question 11

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H₂O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action?

Accepted Answer

Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option A) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option B) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option C) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective: A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately.

Question 12

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly? Select all that apply.

Accepted Answer

11ecbb05_ca79_c090_b433_17446437474e_MD0009_00 The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage (Option A) Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis (Option B) Avoid wearing restrictive clothing or jewelry to prevent thrombosis Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase strength could include squeezing a soft ball or sponge several times a day (Option C) Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting (Option D) Do not sleep on the arm with vascular access or use creams or lotions on the site (Option E) Monitor for signs of infection and bleeding after dialysis and report immediately Keep the site clean to help prevent infection Educational objective: The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein. Clients are taught interventions to help prevent the major complications associated with an AVF (infection, stenosis, thrombosis, and hemorrhage).

Question 13

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive?

Accepted Answer

11ecbb05_ca7b_bc62_b433_fd011b35ca02_MD0009_00 Transurethral resection of the prostate (TURP) involves the insertion of a scope to remove obstructing prostate tissue. Continuous bladder irrigation (CBI) with a 3-way Foley catheter is initiated after the procedure. The catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots are also expected for up to 36 hours after surgery. However, the nurse should adjust the irrigation rate with these normal findings so that the urine remains light pink without clots (Option D). (Option A) Vital signs within normal limits indicate hemodynamic stability but will not reflect the patency of the draining catheter. (Option B) Painful bladder spasms are expected after TURP and catheter placement. Spasms are typically treated with antispasmodics (eg, belladonna-opium suppositories, oxybutynin [Ditropan]). (Option C) The total Foley output should be more than the CBI input, as the Foley output includes CBI fluid (not processed through the kidneys) plus the normal renal output of urine. An obstruction is indicated if the CBI input is equal to or greater than the Foley output. Educational objective: A 3-way Foley catheter with continuous bladder irrigation allows urine to drain after a transurethral resection of the prostate. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots may occur for up to 36 hours. However, the nurse adjusts the irrigation flow to keep the urine light pink without clots.

Question 14

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

Accepted Answer

Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options B, C, and D) These are appropriate interventions but will be more effective if pain is managed first. Educational objective: The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises.

Question 15

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first?

Accepted Answer

11ecbb05_ca7b_6e41_b433_15fa72959fe8_MD0009_00 Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. (Options A and B) Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first. (Option D) Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled out first. Educational objective: Causes of postoperative pain from TURP with a CBI include a kinked blocked catheter, bladder spasms, and general postoperative pain. The nurse should ensure first that urinary flow is intact prior to treating the pain with analgesics.

Question 16

The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate?

Accepted Answer

11ecbb05_ca78_12de_b433_850dde3bae60_MD0009_00 A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with oral trauma or maxillofacial surgery. NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as might occur during an unwitnessed seizure. NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain). Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma (Option A). An NPA may be inserted after imaging (eg, CT scan) rules out fracture. (Option B) Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by auscultating the lungs. (Option C) Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection. To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a diameter smaller than the naris. (Option D) Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to NPA insertion, as these increase the risk of bleeding. However, skull fracture must be excluded prior to placement. Educational objective: A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs should not be inserted in clients with suspected head trauma until skull fracture can be excluded as there is a risk for unintentional malpositioning into underlying tissue/structures (eg, brain).

Question 17

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority?

Accepted Answer

11ecbb05_ca76_da5c_b433_3392a9d90894_MD0009_00 In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space. (Option A) This client's tachycardia and hypotension are likely related to pneumothorax and should improve once the pneumothorax is resolved; administering fluids alone would not help if the pneumothorax continues to worsen. Fluids are given to treat blood loss hypotension, but this should not be the first step in this case. (Option B) Supplemental oxygen should be applied as needed after covering the wound. If possible, correcting the underlying cause is always a priority over treating manifestations. (Option C) After covering the wound, chest tube placement is usually performed to evacuate air and blood from the pleural cavity. The client may need more than one chest tube to evacuate both air (placed higher) and fluid or blood (placed lower). Educational objective: A sucking chest wound indicates a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides.

Question 18

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time?

Accepted Answer

Rib fractures are often the result of blunt thoracic trauma (eg, motor vehicle collision). In the absence of significant internal injuries (eg, pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques (Option A). (Options B and C) Interventions focused on removing secretions to improve gas exchange (eg, ambulation, coughing, incentive spirometry) are appropriate after the client's pain is controlled. (Option D) Rib fractures are very painful. Shallow breathing and reports of pain on inspiration are expected findings that do not require immediate notification of the health care provider. Educational objective: Client management for rib fractures focuses on pain control followed by pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Without adequate pain control, breathing can become shallow, which may lead to buildup of secretions, atelectasis, and pneumonia.

Question 19

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first?

Accepted Answer

Clients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed further for progression. (Option A) Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing), this is not the priority assessment. (Option B) Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. The sound originates from air moving through large airways (bronchi) filled with mucus secretions and are expected in clients with chronic bronchitis. Although they require treatment (eg, medication, mobilization of secretions), this is not the priority assessment. (Option C) The lung under the pleural effusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged. Educational objective: Clients with acute pancreatitis are at high risk for developing acute respiratory distress syndrome.

Question 20

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse?

Accepted Answer

Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair. (Option A) Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration and could impair wound healing. (Option B) Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L). (Option C) The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Educational objective: Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair wound healing.

Exam 1: Adult Health

The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed?

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP) . Oxygen saturation drops to 85% during the night. What is the nurse's first action?

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first?

After receiving a change-of-shift report, the nurse should assess which client first?

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply.

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action?

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly? Select all that apply.

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive?

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI) . The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first?

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority?

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time?

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first?

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse?