During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.)
a. Chest wall ecchymosis
b. Diminished or absent breath sounds
c. Pink-tinged or blood secretions
d. Signs of hypoxia on room air
A, C, D
Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung.
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A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.)
A) Decrease in right atrial pressure leads to closure of the foramen ovale. B) Increase in oxygen levels leads to a decrease in systemic vascular resistance. C) Onset of respirations leads to a decrease in pulmonary vascular resistance. D) Increase in pressure in the left atrium results from increases in pulmonary blood flow. E) Closure of the ductus venosus eventually forces closure of the ductus arteriosus.
According to Peplau, which nursing action demonstrates the nurse's role as a resource person?
A. The nurse balances a safe therapeutic environment to increase the client's sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of "cheeking." D. The nurse explains, in language the client can understand, information related to the client's health care.
A nurse is caring for a client with a myocardial infarction. Which factors could be a cause for the chest pain experienced by the client?
A) Decreased blood supply to the heart muscle B) Atherosclerotic plaques on the coronary artery C) Irregular heart rhythm D) Enlargement of the heart muscle
The nurse is managing care for a client diagnosed with acute renal failure. What does the nurse recognize as the most important safety precaution with regard to medication administration?
1. Review the client's medication regimen to identify any nephrotoxic drugs. 2. Ensure that the client's fluid intake and output are measured precisely. 3. Review the client's medication regimen to identify any drugs that increase fluid retention. 4. Plan to administer less-than-average doses of all medications prescribed for the client.