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NEW QUESTION 43
A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

• A. Wanting attention from the nurses
• B. Having a heart attack
• C. Suffering from complete upper airway obstruction
• D. Hyperventilating

Answer: D

Explanation:
Explanation
(A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.

NEW QUESTION 44
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:

• A. Abdominal pain
• B. Constipation
• C. Urinary frequency
• D. Breast tenderness

Answer: A

Explanation:
(A) Constipation is a result of decreased peristalsis due to smooth muscle relaxation related to changing progesterone levels that occur during pregnancy. (B) Urinary frequency is a common result of the increasing size of the uterus and the resulting pressure it places on the bladder. (C) With the increased vascularity and hypertrophy of the mammary alveoli due to estrogen and progesterone level changes, the breasts will increase in size and may become tender. (D) Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption.

NEW QUESTION 45
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

• A. Purulent
• B. Sanguinous
• C. Serosanguinous
• D. Catarrhal

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous. (B) Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.

NEW QUESTION 46
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:

• A. Suction for a maximum of 30 seconds
• B. Suction for a maximum of 20 seconds
• C. Maintain clean technique during suctioning
• D. Hyperoxygenate before and after suctioning

Answer: D

Explanation:
Section: Questions Set D
Explanation:
(A) The maximum time for suctioning is 10-15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10-15 seconds. (D) Strict sterile technique should be used during suctioning.

NEW QUESTION 47
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