After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
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Solution
Kinked or obstructed chest tube
Option B: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.
Option A: Infection and excessive drainage won’t cause a tension pneumothorax.
Option C: Excessive water won’t affect the chest tube drainage.
Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
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Solution
Place the client on his side, remove dangerous objects, and protect his head.
Option D: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury.
Options A and B: A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration.
The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:
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Solution
The airways are so swollen that no air cannot get through
Option B: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through.
Options A and C: If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern.
Option D: Crackles do not replace wheezes during an acute asthma attack.
Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
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Solution
Fine crackles
Option B: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure.
Option A: Tracheal breath sounds are auscultated over the trachea.
Option C: Coarse crackles are caused by secretion accumulation in the airways.
Option D: Friction rubs occur with pleural inflammation.
Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:
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Solution
A progressively deeper breaths followed by shallower breaths with apneic periods.
Option A: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneas periods.
Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath.
Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.
Option D: Tachypnea is shallow breathing with increased respiratory rate.
A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:
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Solution
Place a saline-soaked sterile dressing on the wound.
Option B: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection.
Options A and C: Then the nurse should call the physician and take the client’s vital signs.
Option D: The dehiscence needs to be surgically closed, so the nurse should never try to close it.
George should be taught about testicular examinations during:
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Solution
Before age 20.
Option D: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.
A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?
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Solution
Avoiding straining during bowel movement or bending at the waist.
Option D: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure.
Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb.
Option B: Instruct the client when lying in bed to lie on either the side or back.
Option C: The client should avoid bright light by wearing sunglasses.
Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
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Solution
Laminectomy
Option A: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning.
Options B and D: Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position.
Option C: Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
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Solution
Increase his activity level.
Option B: The client should be encouraged to increase his activity level.
Options A, C, and D: Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.