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 B

Explanation

A. Taking inhaled beclomethasone with meals is not necessary, as this medication works locally in the lungs and does not require food to be absorbed or tolerated.
B. Rinsing the mouth after using inhaled corticosteroids like beclomethasone is important to prevent the development of oral thrush (a fungal infection) and reduce the risk of other side effects, such as hoarseness.
C. Checking the pulse after medication administration is not required for beclomethasone. While some medications affect heart rate, inhaled corticosteroids like beclomethasone are not typically associated with this effect.
D. Limiting caffeine intake is not necessary when using beclomethasone. Caffeine is a stimulant that may interact with some medications, but it does not typically interfere with corticosteroids used in asthma treatment.

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 providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?

Correct Answer is B

Explanation

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)

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

Explanation

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

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A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)