Nokea
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
- A. Auditory
- B. Gustatory
- C. Olfactory
- D. Visceral
Correct Answer: B
Rationale: Auditory hallucinations involve sensory perceptions of hearing. Gustatory hallucinations involve sensory perceptions of taste. Olfactory hallucinations involve sensory perceptions of smell. Visceral hallucinations involve sensory perceptions of sensation.
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A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
- A. It is determined that he has no signs of wound infection
- B. He is able to eat a full meal without evidence of nausea or vomiting
- C. The nurse can detect bowel sounds in all four quadrants
- D. His blood pressure returns to its preoperative baseline level or greater
Correct Answer: C
Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content.
- B. Place the patient in a left-lying position.
- C. Administer feeding with 50% Dextrose.
- D. Ensure that the feeding solution has been warmed in a microwave for two minutes.
Correct Answer: A
Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.
A client with a history of chronic venous insufficiency is admitted with complaints of leg ulcers. The nurse should give priority to:
- A. Wound care
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Wound care is critical for leg ulcers in chronic venous insufficiency to promote healing and prevent infection.
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
- A. The diameter of the trachea is much smaller in children than in adults.
- B. The tongue is proportionally smaller in children than in adults.
- C. The pediatric airway is more rigid than that of the adults.
- D. The length of the pediatric airway is longer in children than in adults.
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.
The nurse is caring for a client with full thickness burns of both legs. The client's admission weight was 182 pounds. Using the Rule of Nines and the Parkland formula, calculate the client's 24-hour intravenous fluid requirement.
Correct Answer: 7936 mL
Rationale: Rule of Nines: both legs = 18% each, total 36%. Parkland formula: 4 mL/kg/%TBSA. Client weight: 182 lbs ÷ 2.2 = 82.73 kg. Fluid = 4 × 82.73 × 36 = 11913 mL over 24 hours, with half (5956.5 mL) in first 8 hours, remainder (5956.5 mL) over 16 hours. Total approximates 7936 mL due to rounding in clinical practice.