Nokea
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
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The nurse is preparing to insert a peripheral vascular access device. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply sterile dressing over the intravenous site.
- B. Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds.
- C. Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site.
- D. Insert the intravenous catheter at a 15 to 30 degree angle.
- E. Advance the catheter until a flash of blood is seen, then advance the catheter into the vein while removing the needle.
- F. Palpate vein at intended insertion site by pressing downward.
- G. Release tourniquet temporarily.
Correct Answer: C,F,G,B,D,E
Rationale: The correct order ensures proper vein selection, site preparation, catheter insertion, and securement while minimizing complications.
Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.
The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Obtain the client's weight
- B. Ensure ABO type compatibility
- C. Infuse the platelets over 2 to 4 hours
- D. Verify completed consent for platelet transfusion
- E. Obtain pre-transfusion vital signs
Correct Answer: B,D,E
Rationale: Ensuring ABO compatibility prevents transfusion reactions, verifying consent ensures legal and ethical standards, and obtaining pre-transfusion vital signs establishes a baseline for monitoring. Platelet infusions are typically rapid (15–30 minutes), not 2–4 hours, and weight is not routinely required unless dosing is weight-based.
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.