Nokea
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to:
- A. Sit in an upright position and take a deep breath.'
- B. Hold your abdomen firmly with a pillow and take several deep breaths.'
- C. Tighten your stomach muscles as you inhale and relax them as you exhale.'
- D. Raise your shoulders to expand your chest.'
Correct Answer: B
Rationale: Holding the abdomen with a pillow during deep breathing reduces pain and supports the surgical site post-adrenalectomy.
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Which of the following terms describes the condition of a client with the disease in dosage to maintain adequate analgesia?
- A. Pseudoaddiction.
- B. Physical dependence.
- C. Psychological dependence.
- D. Drug tolerance.
Correct Answer: D
Rationale: Drug tolerance occurs when a client requires increased doses to maintain analgesia due to the body's adaptation to the medication.
A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which of the following statements by the nurse will be most helpful to the client?
- A. I have a special medication to decrease secretions.
- B. Avoid fluid intake 2 hours before sexual activity.
- C. Place a thin piece of gauze over the tracheostomy.
- D. Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity.
Correct Answer: C
Rationale: Placing a thin gauze over the tracheostomy can absorb secretions, reducing embarrassment and enabling the client to engage in sexual activity comfortably.
The client with a fractured femur is upset and agitated about her injury and its treatment. She says, 'How can I stay like this for weeks? I can't even move!' Which of the following is the most appropriate nursing diagnosis?
- A. Impaired physical mobility related to traction.
- B. Ineffective coping related to prolonged immobility.
- C. Deficient diversional activity related to prolonged hospitalization.
- D. Activity intolerance related to impaired mobility.
Correct Answer: B
Rationale: Ineffective coping reflects the client's emotional distress and agitation due to immobility.
A client with chemotherapy-induced thrombocytopenia has a platelet count of 18,000/mm³. Which nursing intervention is most important?
- A. Administer aspirin for pain.
- B. Monitor for signs of bleeding.
- C. Encourage vigorous oral hygiene.
- D. Restrict visitors.
Correct Answer: B
Rationale: A platelet count of 18,000/mm³ indicates severe thrombocytopenia, making monitoring for bleeding (e.g., petechiae, epistaxis) the most important intervention to prevent complications.
The sarge department (ED) nurse cares for a client with suspected shock and is prescribed a large volume of sodium chloride (normal saline) The nurse plans on starting which gauge peripheral vascular
- A. 18-gauge
- B. 22-gauge
- C. 24-gauge
- D. 26-gauge
Correct Answer: A
Rationale: An 18-gauge catheter is appropriate for rapid infusion of large fluid volumes in shock.