Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?
A. Respiratory alkalosis
Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.
B. Increased venous return
Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.
C. Decreased cardiac output
Decreased cardiac output is correct. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.
D. Dilated ventricles
Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Medical Surgical Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Reason:
Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.
Choice B Reason:
Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.
Choice C Reason:
Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.
Choice D Reason:
Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.
Similar Questions
A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?
(Select All that Apply.)
A. Sexual intercourse
Sexual intercourse is correct. Stimulation of the genitalia or other areas below the level of injury can trigger autonomic dysreflexia in individuals with spinal cord injuries.
B. Tight clothing
Tight clothing is correct. Any form of tight or restrictive clothing, including belts or waistbands, can stimulate the body below the level of injury and trigger autonomic dysreflexia.
C. Nausea
Nausea is incorrect. While nausea itself is not a common trigger for autonomic dysreflexia, it may occur as a result of the condition. Autonomic dysreflexia can cause a variety of symptoms, including nausea, due to the sudden increase in blood pressure.
D. Surgery below level of injury
Surgery below the level of injury is correct. Surgical procedures performed below the level of the spinal cord injury can lead to stimulation of the body below the injury site, triggering autonomic dysreflexia.
E. Urinary tract infections
Urinary tract infections (UTIs) is correct. Infections of the urinary tract, especially those involving the bladder or urethra, can stimulate the body below the level of injury, leading to autonomic dysreflexia.
Full Explanation
Choice A Reason:
Sexual intercourse is correct. Stimulation of the genitalia or other areas below the level of injury can trigger autonomic dysreflexia in individuals with spinal cord injuries.
Choice B Reason:
Tight clothing is correct. Any form of tight or restrictive clothing, including belts or waistbands, can stimulate the body below the level of injury and trigger autonomic dysreflexia.
Choice C Reason:
Nausea is incorrect. While nausea itself is not a common trigger for autonomic dysreflexia, it may occur as a result of the condition. Autonomic dysreflexia can cause a variety of symptoms, including nausea, due to the sudden increase in blood pressure.
Choice D Reason:
Surgery below the level of injury is correct. Surgical procedures performed below the level of the spinal cord injury can lead to stimulation of the body below the injury site, triggering autonomic dysreflexia.
Choice E Reason:
Urinary tract infections (UTIs) is correct. Infections of the urinary tract, especially those involving the bladder or urethra, can stimulate the body below the level of injury, leading to autonomic dysreflexia.
Which of the following common characteristics of nonallergic asthma can the nurse expect to find when assessing an adult client? (Select all that appl
(Select All that Apply.)
A. Asthma flare-ups during exercise
Asthma flare-ups during exercise is correct . Exercise-induced asthma is a common feature of nonallergic asthma. Physical activity can trigger bronchoconstriction and asthma symptoms in individuals with this type of asthma.
B. Nasal inflammation
Nasal inflammation is incorrect. Nasal inflammation is not typically a characteristic feature of nonallergic asthma. While nasal symptoms such as congestion, rhinorrhea (runny nose), and sneezing are common in allergic asthma due to the involvement of allergic rhinitis (hay fever), they are not typically prominent in nonallergic asthma. Nonallergic asthma primarily affects the lower airways (bronchi and bronchioles) rather than the upper airways (nose and throat). Therefore, nasal inflammation is not commonly associated with nonallergic asthma.
C. No hypersensitivity to allergens
No hypersensitivity to allergens is correct. Unlike allergic asthma, where exposure to allergens triggers asthma symptoms, individuals with nonallergic asthma do not have a hypersensitivity to allergens.
D. Asthma flare-ups with NSAID administration
Asthma flare-ups with NSAID administration is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can trigger asthma symptoms in some individuals with nonallergic asthma.
E. Persistence of manifestations
Persistence of manifestations is correct. Nonallergic asthma tends to have persistent symptoms even in the absence of allergen exposure. Symptoms may occur regularly and may not have a clear seasonal pattern like allergic asthma.
F. Positive response to corticosteroids
Positive response to corticosteroids is correct. Corticosteroids are often effective in managing nonallergic asthma. Individuals with this type of asthma typically respond well to corticosteroid treatment as part of their asthma management plan.
Full Explanation
Choice A Reason:
Asthma flare-ups during exercise is correct . Exercise-induced asthma is a common feature of nonallergic asthma. Physical activity can trigger bronchoconstriction and asthma symptoms in individuals with this type of asthma.
Choice B Reason:
Nasal inflammation is incorrect. Nasal inflammation is not typically a characteristic feature of nonallergic asthma. While nasal symptoms such as congestion, rhinorrhea (runny nose), and sneezing are common in allergic asthma due to the involvement of allergic rhinitis (hay fever), they are not typically prominent in nonallergic asthma. Nonallergic asthma primarily affects the lower airways (bronchi and bronchioles) rather than the upper airways (nose and throat). Therefore, nasal inflammation is not commonly associated with nonallergic asthma.
Choice C Reason:
No hypersensitivity to allergens is correct. Unlike allergic asthma, where exposure to allergens triggers asthma symptoms, individuals with nonallergic asthma do not have a hypersensitivity to allergens.
Choice D Reason:
Asthma flare-ups with NSAID administration is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can trigger asthma symptoms in some individuals with nonallergic asthma.
Choice E Reason:
Persistence of manifestations is correct. Nonallergic asthma tends to have persistent symptoms even in the absence of allergen exposure. Symptoms may occur regularly and may not have a clear seasonal pattern like allergic asthma.
Choice F Reason:
Positive response to corticosteroids is correct. Corticosteroids are often effective in managing nonallergic asthma. Individuals with this type of asthma typically respond well to corticosteroid treatment as part of their asthma management plan.
A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk. Which of the following information should the nurse provide?
(Select All that Apply.)
A. Obtain a hospital bed and keep all four siderails up.
Obtaining a hospital bed and keeping all four siderails up, may not be the best choice. While a hospital bed with siderails may be appropriate for some individuals with Parkinson's disease who are at high risk of falls, keeping all four siderails up continuously can potentially restrict mobility and independence. It's important to balance safety with the client's comfort and ability to move independently.
B. Remove all throw rugs from the home.
Removing all throw rugs from the home is correct. Throw rugs can be tripping hazards, especially for individuals with mobility issues or balance problems. Removing throw rugs can reduce the risk of trips and falls within the home.
C. Install handrails in the bathroom.
Installing handrails in the bathroom is correct. Installing handrails in the bathroom, especially near the toilet and shower, can provide additional support and stability for individuals with Parkinson's disease when performing daily activities. This can help prevent falls in a potentially slippery environment.
D. Ensure adequate lighting along walking spaces.
Ensuring adequate lighting along walking spaces is correct. Good lighting is crucial for individuals with Parkinson's disease to see obstacles and hazards clearly. Adequate lighting along walking spaces helps improve visibility and reduces the risk of falls, especially during nighttime or low-light conditions.
E. Keep walking areas free of clutter.
Keeping walking areas free of clutter is correct. Clutter and obstacles in walking areas increase the risk of tripping and falling, particularly for individuals with Parkinson's disease who may have difficulty with balance and coordination. Keeping walking areas clear of clutter helps create a safer environment.
Full Explanation
Choice A Reason:
Obtaining a hospital bed and keeping all four siderails up, may not be the best choice. While a hospital bed with siderails may be appropriate for some individuals with Parkinson's disease who are at high risk of falls, keeping all four siderails up continuously can potentially restrict mobility and independence. It's important to balance safety with the client's comfort and ability to move independently.
Choice B Reason:
Removing all throw rugs from the home is correct. Throw rugs can be tripping hazards, especially for individuals with mobility issues or balance problems. Removing throw rugs can reduce the risk of trips and falls within the home.
Choice C Reason:
Installing handrails in the bathroom is correct. Installing handrails in the bathroom, especially near the toilet and shower, can provide additional support and stability for individuals with Parkinson's disease when performing daily activities. This can help prevent falls in a potentially slippery environment.
Choice D Reason:
Ensuring adequate lighting along walking spaces is correct. Good lighting is crucial for individuals with Parkinson's disease to see obstacles and hazards clearly. Adequate lighting along walking spaces helps improve visibility and reduces the risk of falls, especially during nighttime or low-light conditions.
Choice E Reason:
Keeping walking areas free of clutter is correct. Clutter and obstacles in walking areas increase the risk of tripping and falling, particularly for individuals with Parkinson's disease who may have difficulty with balance and coordination. Keeping walking areas clear of clutter helps create a safer environment.