Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is A

Explanation

A. Shake the MDI prior to administration: This is the correct action. Shaking the MDI ensures that the medication is evenly mixed with the propellant, which is essential for delivering the correct dose. If the inhaler is not shaken, the medication may not be properly dispensed.
B. Ask the client to inhale the medication quickly for 1 second: This is incorrect. The client should inhale slowly and deeply to ensure the medication reaches the lower airways. A quick inhalation may not allow the medication to be delivered effectively, reducing its therapeutic effect.
C. Wash the MDI canister in warm water after each use: This is incorrect. The MDI canister itself should not be washed as it may damage the device. Only the mouthpiece should be cleaned according to the manufacturer's instructions. Overwashing the device can cause malfunctions.
D. Ask the client to hold their breath for 2 seconds after inhalation: This is too short. The client should hold their breath for about 10 seconds to allow the medication to fully reach the lungs and be absorbed. A brief hold, such as 2 seconds, may not be enough to maximize the medication's effectiveness.

A. Monitor for postural hypotension B. Assess blood glucose level C. Monitor for an irregular heart rate D. Assess for neck vein distention E. Weigh the client daily

Correct Answer is ["B","D","E"]

Explanation

A. Monitor for postural hypotension: This is unlikely in Cushing’s syndrome, where hypertension (not hypotension) is more common due to excess cortisol and fluid retention.
B. Assess blood glucose level: Hyperglycemia is common in Cushing’s syndrome due to the effects of cortisol on glucose metabolism, so monitoring blood glucose levels is essential.
C. Monitor for an irregular heart rate: While Cushing's syndrome can lead to electrolyte imbalances that may affect heart rhythm, this is not a primary intervention in Cushing's syndrome. Monitoring for hypertension and fluid retention is more critical.
D. Assess for neck vein distention: Elevated cortisol levels can lead to fluid retention and hypertension, contributing to neck vein distention, so this is an important observation.
E. Weigh the client daily: Fluid retention and weight gain are key features of Cushing's syndrome, so daily weight monitoring helps assess fluid status and detect rapid weight gain indicative of worsening symptoms.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a metered dose inhaler (MDI) medication to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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