Nokea
A 47-year-old client is admitted for colon surgery. Intravenous antibiotics are started two hours prior to surgery even though the client has no known infection. The reason for giving antibiotics prior to surgery is to:
- A. provide a cathartic action within the colon.
- B. reduce the risk of wound infection from anaerobic bacteria.
- C. relieve anxiety.
- D. reduce the risk of intraoperative fever.
Correct Answer: B
Rationale: Cathartics, not antibiotics, promote the evacuation of intestinal contents. The client undergoing intestinal surgery is at an increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. Antibiotics are indicated in the treatment of infections and have no effect on emotions. Antibiotics would have an effect on an infection which causes a temperature elevation, but they would not directly affect the temperature elevation.
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What is the primary symptom of Bell’s palsy?
- A. Facial drooping
- B. Hearing loss
- C. Eye pain
- D. Tinnitus
Correct Answer: A
Rationale: Bell’s palsy is characterized by sudden onset of unilateral facial drooping due to cranial nerve VII dysfunction.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
- A. Increase the oxygen flow to 3 L/min.
- B. Assess the client's respiratory status.
- C. Call emergency services for the client.
- D. Have the client cough and expectorate secretions.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. This is the priority because the client is experiencing difficulty breathing, which could indicate a worsening of their condition. By assessing the respiratory status, the nurse can gather vital information to determine the appropriate next steps, such as adjusting the oxygen flow rate, providing respiratory treatments, or seeking further medical intervention. Increasing the oxygen flow without assessing the client's condition could potentially exacerbate the issue. Calling emergency services (choice C) may be necessary based on the assessment findings but should not be the immediate priority. Having the client cough and expectorate secretions (choice D) is important for airway clearance but is not the priority when the client is in distress.
8. What is acupuncture used for (select all that apply)?
- A. Relieve pain by causing counterirritation in another area of the body.
- B. Reestablish the flow of Qi through meridians to simulate the body’s self-healing mechanism.
- C. Create an inflammatory response at an acupoint, increasing blood circulation and healing energy.
- D. Relieve nausea and vomiting postoperatively, with pregnancy, or related to chemotherapy.
Correct Answer: B
Rationale: Acupuncture is commonly used to reestablish the flow of Qi (option B) and relieve nausea and vomiting (option D), among other therapeutic uses.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Preoxygenating the client with 100% oxygen for up to 3 minutes helps prevent hypoxia during suctioning.
2. COPD patients are at higher risk for hypoxia due to impaired gas exchange.
3. Preoxygenation helps maintain oxygen saturation levels and reduces the risk of complications.
4. This action supports safe and effective nasotracheal suctioning in clients with COPD and an artificial airway.
Summary:
- Option A: Performing suctioning for up to four passes can increase the risk of hypoxia and mucosal damage.
- Option B: Applying suction to the catheter during advancement can cause trauma and increase the risk of infection.
- Option D: Limiting each suction pass to 25 seconds may not provide adequate time for effective suctioning in clients with COPD and artificial airways.
Which patient is ready for discharge from Phase I PACU care to the clinical unit?
- A. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
- B. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
- C. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
- D. Arouses, blood pressure (BP) higher than preoperative and respiratory rate is 10, no excess bleeding, SaO2 is 90%
Correct Answer: C
Rationale: Stable vital signs, intact dressing, and adequate oxygenation indicate readiness for transfer.