A patient comes to the emergency room with a possible pneumothorax. The nurse should assess for
which of the following?
1
.
Rapid respirations.
2
.
Deep, rapid respirations.
3
.
Respiratory depression.
4
...
A patient comes to the emergency room with a possible pneumothorax. The nurse should assess for
which of the following?
1
.
Rapid respirations.
2
.
Deep, rapid respirations.
3
.
Respiratory depression.
4
.
Periods of hyperpnea alternating with periods of apnea.
Strategy: Think about each answer.
1) CORRECT— describes tachypnea
2) hyperpnea; causes include metabolic acidosis, diabetic ketoacidosis
3) occurs with drug overdose
4) Cheyne-Stokes respirations; crescendo breathing; cause is cerebral lesion
The nurse prepares a client for a barium enema. It is MOST important for the nurse to include which of
the following instructions?
1
.
“Your stool will be light-colored for 2 to 3 days after the test.”
2
.
“Once the test is over and you go to the toilet, you will be able to resume normal
activities.”
3
.
“The x-ray table will be tilted so you can assume various positions.”
4
.
“During the test, it is crucial that you take slow, deep breaths through your mouth.”
Strategy: “MOST important” indicates priority.
1) accurate information but not the most important
2) after the rectal tube is removed and client evacuates the bowels, additional x-rays are taken;
due to the bowel prep and procedure, most clients require a period of rest after the test
3) accurate information but not the most important; reassure client that he will be secure on the
table during the x-rays
4) CORRECT— for test to be successful, client must retain barium; as barium is introduced,
client may have the urge to defecate; slow, deep breathing will help ease the discomfort
The nurse counsels a client newly diagnosed with hypertension. Which of the following statements, if
made by the client to the nurse, indicates that teaching is successful?
1
.
"If I feel dizzy when I wake up, I will skip my morning blood-pressure pill."
2
.
"I will switch from lifting weights at the health club to doing aerobics."
3
.
"I will be sure to take chlorothiazide (Diuril) every night before I go to bed."
4
.
"I will take hot baths or go to the sauna to relax if I feel tension coming on."
Strategy: "Teaching is successful" indicates correct information.
(1.) medication needs to be taken on a regular basis; instruct to rise slowly from lying and sitting
positions; if severely bothered by dizziness, contact physician
(2.) CORRECT—regular aerobic exercises are usually recommended; isometric exercises such
as heavy weight-lifting and rowing are contraindicated, can cause a dangerous rise in blood
pressure due to a vasovagal response during intense isometric muscle contraction
(3.) thiazide diuretic; nighttime dosing will interfere with sleep by requiring frequent urination
(4.) not best; antihypertensives (and diuretics) commonly cause hypotension and heat can
facilitate hypotension
An older client diagnosed with emphysema becomes restless and confused. The nurse should take which
of the following actions?
1
.
Encourage the client to perform pursed lip breathing.
2
.
Check the client’s temperature.
3
.
Assess the client’s potassium level.
4
.
Increase the oxygen flow rate to 5 L/min.
Strategy: Determine whether it is appropriate to assess or implement.
1) CORRECT— prevents collapse of lungs; helps patient control rate and depth of breathing
2) confusion probably due to decreased oxygenation
3) confusion not due to potassium imbalance
4) should receive low oxygen flow to prevent CO 2 narcosis
The nurse cares for a client 1 day after abdominal surgery. The nurse notes that the client is 5 ft, 3 in tall;
weighs 210 lb; BP 130/80; pulse 76; and respirations 14/min. The client complains of pain, and the nurse
administers meperidine (Demerol) 75 mg. and promethazine (Phenergan) 50 mg IM. Two hours later the
client reports no relief from the pain. Which of the following actions by the nurse is MOST appropriate?
1
.
Assess the client’s mental status.
2
.
Contact the physician.
3
.
Observe the abdominal wound.
4
.
Explain to the client that abdominal wounds are painful.
Strategy: “MOST appropriate” indicates priority
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