Nokea
A 27-year-old female has had elective nasal surgery for a deviated septum. Which of the following would indicate that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Nausea.
- B. Repeated swallowing.
- C. Increased respiratory rate.
- D. Increased pain.
Correct Answer: B
Rationale: Repeated swallowing may indicate blood trickling down the throat (postnasal drip), a sign of bleeding. Nausea, increased respiratory rate, and pain are less specific indicators of bleeding.
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A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
- A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
- B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
- C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
- D. I can see that you are upset. Would you like to share your concerns with me?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
The nurse is caring for a client receiving a unit of packed red blood cells (PRBCs). The client reports chills, and their oral temperature is 103° F (39.4° C). Which action should the nurse take first?
- A. Assess the client's blood pressure and heart rate
- B. Obtain blood cultures
- C. Pause the transfusion
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: C
Rationale: Chills and a fever of 103°F during a PRBC transfusion suggest a possible febrile or hemolytic reaction. The first action is to pause the transfusion to prevent further administration of potentially problematic blood. Assessing vital signs, obtaining cultures, and notifying the provider follow after stopping the transfusion.
A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
- A. Reduce the client's anxiety.
- B. Maintain adequate oxygenation.
- C. Decrease chest pain.
- D. Maintain adequate circulating volume.
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
The nurse is reviewing a new prescription for amphotericin b. The nurse recognizes that this medication is prescribed to treat
- A. autoimmune infections.
- B. fungal infections.
- C. viral infections.
- D. bacterial infections.
Correct Answer: B
Rationale: Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is not used for autoimmune (A), viral (C), or bacterial (D) infections.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.