Test Taking Practice

The nurse is caring for a client who experienced blunt chest trauma and has been prescribed oxygen and frequent assessments. Upon assessment, there is a new tracheal shift to the right, absence of lung sounds on the left side, dullness on percussion of the left chest, and HR 135 and BP 72/40. The nurse suspects the patient has developed which of the following complications?

• Cardiac tamponade

• Massive hemothorax

• Flail chest

• Pleural effusion

Answer explanation

The client is likely experiencing a hemothorax. Tracheal deviation to the right, away from the side where the lung sounds are absent, indicates that something is filling the space (i.e. blood). The lack of breath sounds does not help distinguish between hemothorax and pneumothorax as both would result in absent breath sounds. Dullness on percussion indicates fluid in the space. Pleural effusions, which is a collection of fluid in the pleural space, result in muffled breath sounds. Flail chest occurs when sections of ribs are fractured, which causes a paradoxical chest movement.

The nurse is reassessing a client after resuscitative efforts. Which finding indicates the disability component of the ABCDE approach is intact?

• Client has a GCS score of 15

• Lung sounds are clear bilaterally

• Capillary refill is 2 seconds

• Client is responsive to pain

Answer explanation

The ABCDE approach is a rapid assessment of emergency conditions. The disability component represents the “D” in ABCDE. Disability determines the client’s level of consciousness. The Glasgow Coma Scale (GCS) is based on eye-opening, verbal, and motor responses. The normal finding is a score of 15. Clear lung sounds evaluate breathing, the “B” in the ABCDE approach. Capillary refill of 2 seconds is a normal finding for circulation, the “C” in the ABCDE approach. A client who is responsive to pain does not have an intact level of consciousness.

The nurse is admitting a client with a history of end-stage renal disease who was found unresponsive at home. The client has a history of chronic hemodialysis. The EKG is displaying bradycardia and peaked t-waves. Which of the following immediate interventions should be anticipated?

• 50% dextrose and regular insulin administered intravenously

• Insertion of central venous line

• Oral administration of kayexalate

• Initiation of a hemodialysis treatment

Answer explanation

Hyperkalemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with kidney disorders. Therefore, the patient is monitored for potassium values greater than 5.0 mEq/L (5 mmol/L), ECG changes (tall, tented, or peaked T waves), and changes in clinical status. If the patient is hemodynamically unstable (low blood pressure, changes in mental status, or dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be given to shift potassium back into the cells. The shift of potassium into the intracellular space is temporary, so arrangements for dialysis will then need to be made.

The nursing supervisor is working in a hospital that is in the path of a hurricane. Which client would be appropriate for immediate discharge?

• The client with nondisplaced tibia fracture that has been immobilized

• The client with lymphoma receiving induction IV chemotherapy

• The client with heart failure who is receiving 8 liters of oxygen

• The client who had an appendectomy with a paralytic ileus

Answer explanation

Medically unstable and unpredictable critical care patients are not candidates for discharge. Stable clients who need assistance are the second priority and, therefore, not discharged until the lowest priority clients are discharged. Ambulatory clients who need no assistance are the first clients to be safely discharged and relocated. The lowest acuity client here is the tibia fracture as this injury does not require surgical intervention. Clients who are receiving high flow oxygen, IV medication, and experiencing complications should not be discharged.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

• Weight loss and dry skin

• Flat neck and hand veins and decreased urinary output

• An increase in blood pressure and increased respirations

• Weakness and decreased central venous pressure (CVP)

Answer explanation

A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6°F (38.1°C) orally. Which action should the nurse take?

• Begin the transfusion as prescribed.

• Administer an antihistamine and begin the transfusion.

• Delay hanging the blood and notify the health care provider (HCP).

• Administer 2 tablets of acetaminophen and begin the transfusion.

Answer explanation

If the client has a temperature higher than 100°F (37.8°C), the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.

Which finding suggests to the nurse that a client with bleeding esophageal varices is experiencing a side or adverse effect of vasopressin therapy?

• Complaints of chest pain

• Bounding peripheral pulses

• Temperature of 102°F (39.8°C)

• Blood urea nitrogen (BUN) of 20 mg/dL (7.1 mmol/L)

Answer explanation

Vasopressin therapy causes vasoconstriction, and side and adverse effects include myocardial ischemia, which may be evident by the client's complaints of chest pain. Elevated temperature, bounding peripheral pulses, and a BUN of 20 mg/dL (7.1 mmol/L) are not adverse effects. Vasopressin therapy can cause hypothermia. Because vasopressin has potent vasoconstrictive effects on the peripheral arterioles, weak versus bounding pulses may be found. The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L).

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply.

• "I need to sit whenever possible."

• "I need to be sure to eat a balanced diet."

• "I need to take a hot bath every evening."

• "I need to rest for long periods of time every day."

• "I should engage in moderate low-impact exercise when I am not tired."

Answer explanation

Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?

• Suggesting a reduction of medication

• Allowing increased "in-room" activities

• Increasing the level of suicide precautions

• Allowing the client off-unit privileges as needed

Answer explanation

A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result should the nurse review as the priority?

• Sodium level

• Digoxin level

• Creatinine level

• Potassium level

Answer explanation

Diuretic therapy can cause hypokalemia. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.