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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Test your blood glucose level every 8 hours.": This is incorrect. During illness, blood glucose levels should be checked more frequently, typically every 2 to 4 hours, to closely monitor for hyperglycemia and prevent diabetic ketoacidosis (DKA). Checking every 8 hours may not be frequent enough, especially if the client is ill or experiencing stress, both of which can affect blood sugar.
B. "Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.": This is the correct instruction. When blood glucose levels exceed 240 mg/dL, it is important to check for ketones in the urine. The presence of ketones can indicate the development of DKA, and early detection can prevent the condition from worsening.
C. "Withhold your usual daily dose of insulin.": This is incorrect. Insulin should never be withheld during periods of illness unless specifically instructed by a healthcare provider. Withholding insulin can increase the risk of DKA, as the body will continue to break down fat for energy in the absence of insulin, leading to ketosis.
D. "Drink 240 to 360 milliliters of calorie-free liquids every 8 hours.": This is not entirely correct. While staying hydrated is important, the recommendation is generally to drink more frequently, ideally 8 ounces of fluid every hour to stay well-hydrated. It is also recommended to drink fluids that contain some carbohydrates (such as electrolyte-containing drinks) to help manage blood glucose levels during illness.

A. Tissue integrity B. Airway patency C. Pain severity D. Wound drainage

Correct Answer is B

Explanation

A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Correct Answer is B

Explanation

After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Which side effect of radiation therapy will the nurse anticipate in a patient who has laryngeal cancer?

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis?

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

Mr. Jones is undergoing an open lung biopsy in the morning, and the nurse is educating the patient regarding the postoperative period. Which of the following statements should be included in the education?

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?