Clinical Judgments

Question 1

Which clinical findings would the nurse expect a client diagnosed with ulcerative colitis to report? Select all that apply.

Answer 1

Correct1 Fever
Correct2 Diarrhea
3 Gain in weight (Weight loss would be correct)
4 Spitting up blood
Correct5 Abdominal cramps
The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Also, hemoptysis (coughing up blood from the respiratory tract) is not a related sign.

Question 2

Alprazolam is prescribed for a client who is anxious. For what therapeutic effect will the nurse monitor the client?

Answer 2

1 Reduced anger
 Correct2 Resting quietly
3 Sleeping soundly
4 Reduced blood pressure
Alprazolam, an anxiolytic, promotes muscle relaxation, reduces anxiety, and facilitates rest. Possible adverse reactions to alprazolam are anger and hostility. Although drowsiness is a side effect of alprazolam, caused by depression of central nervous system activity, it is not a hypnotic. Transient hypotension is a side effect of alprazolam, but this is not why it is given to an anxious client.

Question 3

What clinical findings does a nurse expect when assessing a child with acute laryngotracheobronchitis? Select all that apply.

Answer 3

Correct1  Fever
2 Crackles: NO crackles
 Correct3  Hoarseness
 Correct4 Barking cough
 Correct5 Inspiratory stridor
Fever is a common finding with acute laryngotracheobronchitis. Hoarseness is caused by edema of the mucosa of the larynx. The cough is tight, with a barking, metallic sound due to laryngeal edema. Children with acute laryngotracheobronchitis experience inspiratory stridor because of laryngeal edema. Crackles are not characteristic of acute laryngotracheobronchitis.

Question 4

A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms?

Answer 4

Distended neck veins
Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.

Question 5

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?

Answer 5

Correct1  Oxygen Saturation: 89%
2 Body temperature: 101°F
3 Blood Pressure: 130/80 mmHg
4 Respiratory rate: 26 beats/minute
An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client’s body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

Question 6

Which is likely to impact a child’s drawing near the end of the preschool stage of development? Select all that apply.

Answer 6

Correct 1 Culture
2 Disease
 Correct 3 Environment
4 Physical growth
5 Hand dominance
Culture and environment are thought to impact a child’s drawing near the end of the preschool stage of development as all drawings tend to look the same until the end of this stage. Disease, physical growth, and hand dominance are not thought to impact a child’s drawing.

Question 7

Which trait should the nurse expect when assessing a preschool-age client who is considered gifted?

Answer 7

1 Poor language development
2 Pronounced short-term memory
Correct 3 Talented in one area, such as drawing
4 Interests similar to other children of the same age
Data that the nurse would expect when assessing a preschool-age client who is considered gifted is that the child will have a significant talent in one area, such as drawing. Advanced, not poor, language development is expected. A pronounced long-, not short-, term memory is anticipated. The child will have interests similar to older children, not children of the same age.

Question 8

A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant’s hydration status?

Answer 8

1 Counting wet diapers
 Correct2 Obtaining daily weights
3 Measuring intake and output
4 Checking tissue turgor of the abdomen
Daily weighing provides an objective measurement, because a weight loss indicates a loss of fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an objective measure, it is necessary to weigh the diapers before and after the infant voids to estimate the amount of fluid loss. Intake can be measured accurately; however, output, especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open to a variety of interpretations. Also, the site that should be assessed is over the sternum, not the abdomen.

Question 9

The nurse is providing education to the parents of a preschool-age client who is obese. Which parental statements indicate correct understanding of the information presented? Select all that apply.

Answer 9

Correct1 “I should avoid giving sugar-sweetened beverages to my child.”
2 “It is ok for my child to watch 3 to 4 hours of television per day.”
3 “My child should have 3 to 5 servings of carbohydrates each day.”
Correct4 “My child should have 5 servings of fruits and vegetables each day.”
Correct5 “It is important for my child to have at least 1 hour of activity per day.”
An obese child should avoid sugar-sweetened beverages; eat 5 servings of fruits and vegetables each day; and have at least 1 hour of activity; therefore, these statements indicate correct understanding of the information presented. Television time should be limited to 1 hour each day. Currently there are no recommendations related to carbohydrate consumption.

Question 10

Which client should a nurse consider the greatest risk for developing hypernatremia?

Answer 10

1 A 52-year-old who is receiving 0.45% NaCl intravenously
2 A 76-year-old who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a result of head trauma
Correct 3 A 63-year-old who has had watery diarrhea since traveling abroad
4 A 48-year-old who is admitted with a diagnosis of Addison disease
Watery diarrhea involves loss of water in excess of sodium; this leads to an increased sodium concentration. Intravenous 0.45% NaCl is a hypotonic solution; concentration of sodium is less than body fluids. Increased secretion of antidiuretic hormone causes water retention, which decreases sodium concentration. Addison disease involves hyposecretion of adrenocortical hormones, which leads to hyponatremia.

Question 11

Before the administration of Rho(D) immune globulin, the nurse reviews the laboratory data of a pregnant client. Which blood type and Coombs test result must a pregnant woman have to receive Rho(D) immune globulin after giving birth?
1 Rh positive and Coombs positive
2 Rh negative and Coombs positive
3 Rh positive and Coombs negative
4 Rh negative and Coombs negative

Answer 11

4 Rh negative and Coombs negative

Rho(D) immune globulin is given to an Rh-negative mother after birth if the infant is Rh positive and the Coombs test reveals that the mother was not previously sensitized (negative). An Rh-positive mother will not develop antibodies to a fetus who is either Rh positive or Rh negative; therefore the Coombs test is not performed. An Rh-negative mother with a positive Coombs test result indicates she has Rh-positive antibodies; therefore Rho(D) immune globulin is not given because it will not be effective.

Question 12

An intravenous solution containing potassium inadvertently has infused too rapidly. The healthcare provider prescribes insulin added to a 10% dextrose in water solution. What does the nurse identify as the purpose of the insulin?

1 Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level.
2 Increased insulin accelerates excretion of glucose and potassium, thereby decreasing the serum potassium level.
3 Glucose with insulin increases metabolism, which accelerates potassium excretion.
4 Increased potassium causes a temporary slowing of pancreatic production of insulin.

Answer 12

Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level.

Increased potassium causes a temporary slowing of pancreatic production of insulin.
Potassium follows insulin into the cells of the body, thereby raising the intracellular potassium level and preventing fatal dysrhythmias. Insulin does not cause excretion of these substances. Potassium is not excreted as a result of this therapy; it shifts into the intracellular compartment. The potassium level has no effect on pancreatic insulin production.

Question 13

Which respiratory infections should the nurse monitor the toddler-age client for based on structural differences during this stage of development? Select all that apply.

Bronchiolitis

Ear infection

Acute sinusitis

Laryngotracheobronchitis

Inflammation of the tonsils

Answer 13

Correct2 Ear infection
Correct3 Acute sinusitis
Correct5 Inflammation of the tonsils
The toddler-age client remains at risk for ear infection (otitis media), acute sinusitis, and inflammation of the tonsils or tonsillitis; therefore, the nurse should assess the toddler-age client for these infections due to the angle of the Eustachian tube in the ear. Bronchiolitis and laryngotracheobronchitis (croup) are more common during infancy.

Question 14

A client with cholelithiasis has a laser laparoscopic cholecystectomy. What is most appropriate for the nurse to do postoperatively?
1 Maintain the client’s nothing by mouth status for the first 24 hours
2 Monitor the client’s abdominal incision for bleeding
3 Offer clear carbonated beverages to the client
4 Ambulate the client when the client is alert and oriented

Answer 14

4 Ambulate the client when the client is alert and oriented

The client should be ambulated as soon as they are alert and oriented. Recovery will be rapid because there is no large abdominal incision. Clear liquids may be started as soon as the client is awake and a gag reflex has returned. With a laparoscopic cholecystectomy there will be one or more puncture wounds, not an incision, on the abdomen. Carbonated beverages will create gas, which will distend the intestines and increase pain.

Question 15

The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client’s fluid replacement is adequate?

1 Increasing hematocrit level
2Urinary output of 15 to 20 mL/hr
3Slowing of a previously rapid pulse rate
4Central venous pressure progressing from 5 to 1 mm Hg

Answer 15

Slowing of a previously rapid pulse rate

The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/hr indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/hr. Central venous pressure decreasing from 5 to 1 mm Hg indicates hypovolemia.
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Question 16

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?
1 Increased restlessness
2 No secretions when client is suctioned
3 PaO2 of 93
4 Skin warm and dry

Answer 16

1 Increased restlessness

Signs of poor oxygenation in the client on a ventilator may include, but are not limited to, the following: cyanosis; PaO2 less than 90; increased restlessness or agitation; skin pale, cool, and clammy; and thick, tenacious secretions present when suctioned.

Question 17

A 16-year-old girl at 28-weeks’ gestation arrives at the prenatal clinic with her mother for a routine sonogram. Before the procedure, the girl asks that the nurse not reveal the fetus’s sex if it should become apparent. Afterward, the mother asks the nurse the sex of the fetus. In light of the mother-daughter relationship, what is the best response by the nurse at this time?
1 “That information is not available at this time.”
2 “I’m not allowed to divulge confidential information.”
3 “Your daughter asked me not to give that information to anyone.”
4 “The sex of the baby isn’t the most important information at this time.”

Answer 17

1 “That information is not available at this time.”

Stating that the information is not available at this time supports the client’s right to confidentiality without antagonizing the client’s mother. Because the expectant mother has requested that the sex of the fetus not be revealed, she has legally and ethically made this information unavailable. Although stating that the nurse is not allowed to divulge that information or that the client has asked it not be given protect the client’s right to confidentiality, these responses could disrupt the relationship between the client and her mother. Stating that the sex of the baby isn’t the most important information at this time is a judgmental, nontherapeutic statement.

Question 18

When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal.

return of appetite
muscle twitching
runny nose and irrritability
flulike symptoms

Answer 18

.1
Runny nose and irritability

2.
Muscle twitching
 Correct
3.
Flulike syndromes
 Correct
4.
Return of appetite
When opioids, which are central nervous system depressants, are withdrawn initially, the client will experience a runny nose (rhinorrhea), tearing (lacrimation), diaphoresis, yawning, and irritability. As withdrawal progresses, rebound hyperexcitability precipitates muscle twitching, restlessness, hypertension, tachycardia, temperature irregularities, tremors, and loss of appetite. Finally flulike symptoms, insomnia, and yawning occur. Once withdrawal is complete the appetite returns, vital signs become stable, and other withdrawal signs and symptoms subside and eventually disappear.

Question 19

The nurse is assessing abdominal flanks in a client as part of the secondary survey. In which order should the nurse perfo Correct
1.
Look for symmetry of abdominal wall and bony structures.
Correct
2.
Inspect for external signs of injury, bruises, abrasions, lacerations, punctures, and old scars.
Correct
3.
Auscultate for bowel sounds.
Correct
4.
Palpate for masses, guarding, and femoral pulses.
Correct
5.
Note type and location of pain, rigidity, or distention of abdomen.

Answer 19

Correct
1.
Look for symmetry of abdominal wall and bony structures.
Correct
2.
Inspect for external signs of injury, bruises, abrasions, lacerations, punctures, and old scars.
Correct
3.
Auscultate for bowel sounds.
Correct
4.
Palpate for masses, guarding, and femoral pulses.
Correct
5.
Note type and location of pain, rigidity, or distention of abdomen.
Assessment of abdominal flanks is done in the secondary survey. The nurse should start the assessment by looking for symmetry of the abdominal wall and bony structures. This should be followed by inspecting for external signs of injury, bruises, abrasions, lacerations, punctures, and old scars. Then auscultating for bowels sounds is performed followed by palpating for masses, guarding, and a femoral pulse. This should be followed by noting the type and location of pain, rigidity, or any distention of the abdomen.

Question 20

An older client comes to the emergency department after three days of diarrhea and is admitted to the hospital for rehydration therapy. In addition to sodium, what electrolyte should the nurse be concerned about most when the client's laboratory results are documented?
1 Calcium
2 Chlorides
3 Potassium
4 Phosphates

Potassium, sodium, and bicarbonate are the electrolytes most often lost with diarrhea. With diarrhea, these electrolytes are excreted via the gastrointestinal tract before they can be absorbed. Hypokalemia can cause cardiac dysrhythmias. Serum calcium levels are related to parathyroid function and calcium metabolism. Although the chloride level may be affected by diarrhea, it is not the greatest concern. Phosphate levels are regulated by calcium metabolism and parathormone.

Answer 20

Potassium

Potassium, sodium, and bicarbonate are the electrolytes most often lost with diarrhea. With diarrhea, these electrolytes are excreted via the gastrointestinal tract before they can be absorbed. Hypokalemia can cause cardiac dysrhythmias. Serum calcium levels are related to parathyroid function and calcium metabolism. Although the chloride level may be affected by diarrhea, it is not the greatest concern. Phosphate levels are regulated by calcium metabolism and parathormone.

Question 21

A client has been actively hallucinating for several days. What is the most therapeutic nursing intervention?

2 Involving the client in simple activities on the unit
3 Allowing the client to continue without interruption
4 Having the client frequently repeat what the voices are saying

The nursing goal is to promote reality; simple activities do not place demands on the client. Asking the client who is speaking implies that the client is talking to a real person. Allowing the client to continue without interruption allows further withdrawal rather than orienting the client to reality. The client should be asked occasionally to repeat what the voices are saying so the nurse can identify command hallucinations; once a day or when there is a change in the client’s behavior is sufficient. It should not be done frequently because it may reinforce the hallucinations.

Answer 21

Involving the client in simple activities on the unit

The nursing goal is to promote reality; simple activities do not place demands on the client. Asking the client who is speaking implies that the client is talking to a real person. Allowing the client to continue without interruption allows further withdrawal rather than orienting the client to reality. The client should be asked occasionally to repeat what the voices are saying so the nurse can identify command hallucinations; once a day or when there is a change in the client’s behavior is sufficient. It should not be done frequently because it may reinforce the hallucinations.

Question 22

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that 1 
Seizures
2 
Vomiting
3 
Bulging fontanels
4 
Subnormal temperature
5 
Decreased respiratory rate

Answer 22

Seizures

Vomiting

Decreased respiratory rate

Irritation of cerebral tissue can cause seizures. Pressure on vital centers can cause vomiting. Pressure on the respiratory center results in a decreased respiratory rate. A 2-year-old child’s fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. The inflammatory process of meningitis causes an increase in temperature.

Question 23

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, “I can’t take this a minute longer.” What does this behavior indicate to the nurse caring for her?
1
There was no preparation for labor.
2
She should receive an analgesic for pain.
3
She is entering the transition phase of labor.
4
Hypertonic uterine contractions are developing.
The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.

Answer 23

She is entering the transition phase of labor.

Hypertonic uterine contractions are developing.
The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.

Question 24

6.
A newborn has just begun to breast-feed for the first time. Although the neonate has latched on to the mother’s nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse best intervene at this time?
1
Tell the client to use the other breast and continue breast-feeding
2
Delay the feeding to allow more time for the infant to recover from the birthing process
3
Contact the lactation consultant to help the client learn a more successful breast-feeding technique
4
Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula
Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breast-feeding techniques.

Answer 24

Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula

Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breast-feeding techniques.

Question 25

After teaching, the registered nurse is evaluating the statements of a licensed coworker about osteoporosis. Which statement made by the licensed coworker indicates the nurse needs to follow up?
1
“I should give milk to the client daily.”
2
“I should not allow the client to make movements.”
3
“I should give the pain killers only upon prescription.”
4
“I should ambulate the client in the sunlight.”

Answer 25

“I should not allow the client to make movements.”

Because it may result in permanent immobility, clients with osteoporosis should not remain immobile. Therefore, the coworker’s statement that the client should not be allowed to make movements indicates the need for follow up by the nurse to correct this misconception. Milk is rich in calcium and should be given to clients with bone disorders. Licensed personnel cannot give any medication to the client unless prescribed by the primary healthcare provider. Sunlight is a good source of vitamin D, which is required for calcium absorption; therefore ambulating the client in the sun would be beneficial.

Question 26

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate?
1
Hypernatremia
2
Hyperchloremia
3
Metabolic alkalosis
4
Respiratory acidosis

Answer 26

Metabolic alkalosis

The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.

Question 27

A client had surgery for a strangulated hernia. One hour after surgery the client’s blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. What action 1
Place the client in the left side-lying position.
2
Instruct the client to move both legs.
3
Notify the primary healthcare provider immediately.
4
Administer the prescribed pain medication.

Answer 27

2
Instruct the client to move both legs.

The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. Turning the client onto the left side will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. Calling the healthcare provider eventually may be done after performing the initial interventions and evaluating results. Opioid analgesics may decrease the blood pressure further.

Question 28

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse’s conclusion? Select all that apply.

Polyuria

Polydipsia

Polyphagia

Polyphrasia

Polydysplasia

Answer 28

Polyuria

Polydipsia

Polyphagia

Polyuria is excessive urination associated with osmotic diuresis. Polydipsia is excessive thirst associated with hyperglycemia; thirst is the response to osmotic diuresis and glycosuria. Polyphagia is associated with the catabolic state induced by insulin deficiency. Polyphrasia is excessive talking associated with mental illness, not hyperglycemia. Polydysplasia is related to multiple developmental abnormalities and is unrelated to hyperglycemia.

Question 29

A client has cholelithiasis with possible obstruction of the common bile duct. What should be determined about the client’s nutritional status before surgery is scheduled?
1
Is the client deficient in vitamins A, D, and K?
2
Does the client eat adequate amounts of dietary fiber?
3
Does the client consume excessive amounts of protein?
4
Are the client’s levels of potassium and folic acid increased?

Answer 29

Is the client deficient in vitamins A, D, and K?

Bile promotes the absorption of fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum, limiting absorption of fat-soluble vitamins A, D, and K. Vitamin K helps with clotting; surgery can be postponed if bleeding problems exist. Knowing if the client eats adequate amounts of dietary fiber is not relevant to the situation. Knowing if the client consumes excessive amounts of protein is unnecessary; however, protein is desirable for wound healing. Increases in potassium and folic acid are not expected with this disease.

Question 30

Which assessment finding in a pregnant client should prompt the nurse to notify the primary healthcare provider?
1
Slight dependent edema at 38 weeks’ gestation
2
Fundal height at the umbilicus at 16 weeks’ gestation
3
Fetal heart rate of 150 beats/min at 24 weeks’ gestation
4
Maternal heart rate of 92 beats/min at 28 weeks’ gestation

Answer 30

Fundal height at the umbilicus at 16 weeks’ gestation

Fundal height should be at the umbilicus at 20 weeks’ gestation. This early fundal height increase indicates a hydatidiform mole, a multiple gestation, or a fetal congenital anomaly; at 16 weeks’ gestation the fundus is below the umbilicus in a healthy, single pregnancy. Foot and ankle edema is common as pregnancy reaches term; the enlarged uterus presses on the femoral veins, impeding the flow of venous blood from the extremities. A fetal heart rate of 150 beats/min at 24 weeks’ gestation and a maternal heart rate of 92 beats/min at 28 weeks’ gestation are within the expected ranges during pregnancy.

Question 31

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client’s vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?
1
Give naloxone intravenous push med (IVP) per protocol.
2
Assess the client’s pain level on a 10-point scale.
3
Document the findings and reassess in 2 hours.
4
Call the rapid response team.

Answer 31

Give naloxone intravenous push med (IVP) per protocol.

A respiratory rate of 10 breaths/min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.

Question 32

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client?
1
Mediastinal shift
2
Tracheal laceration
3
Open pneumothorax
4
Pericardial tamponade

Answer 32

Mediastinal shift

Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

Question 33

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?
1
Warming the newborn
2
Clamping the umbilical cord
3
Assessing maternal bleeding
4
Monitoring expulsion of the placenta

Answer 33

Warming the newborn

Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. The cord may be left intact until the newborn’s temperature has stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother; the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

Question 34

A nurse working in a disaster management team is caring for clients who suffered severe injuries in a train accident requiring cardiopulmonary resuscitation. Which statements by the nurse are correct? Select all that apply.
1
“A 16-gauge needle should be used to obtain intravenous (IV) access in the antecubital region.”
2
“When resuscitating a client, blood pressure can be easily assessed using a manual cuff.”
3
“Presence of carotid pulse indicates a minimum diastolic pressure of 60 mm Hg.”
4
“Presence of radial pulse indicates a minimum systolic blood pressure of 80 mm Hg.”
5
“Hypotension occurs after the body’s compensatory mechanism to maintain vital signs is exhausted.”

Answer 34

Correct1
“A 16-gauge needle should be used to obtain intravenous (IV) access in the antecubital region.”

Correct4
“Presence of radial pulse indicates a minimum systolic blood pressure of 80 mm Hg.”
Correct5
“Hypotension occurs after the body’s compensatory mechanism to maintain vital signs is exhausted.”
A 16-gauge needle is best indicated to achieve initial IV access. The presence of a radial pulse in a client requiring cardiopulmonary resuscitation (CPR) indicates that the systolic blood pressure is at least 80 mm Hg. Exhaustion of the body’s compensatory mechanism yields symptoms of hypotension. During CPR, assessing the radial, femoral, and carotid pulse rate can give effective estimations of blood pressure values; the use of a manual cuff is not necessary and may not be feasible. Presence of carotid pulse in a client requiring CPR indicates that the systolic, not diastolic, blood pressure is at least 60 mm Hg.

Question 35

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?
1
Increased blood urea nitrogen (BUN) and hypotension
2
Hyperkalemia and poor skin turgor
3
Hyponatremia and decreased urine output
4
Polyuria and increased specific gravity of urine

Answer 35

Hyponatremia and decreased urine output

Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.