Nokea
A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report?
- A. Repeated episodes of nausea and vomiting
- B. Complaints of pain associated with exertion
- C. Failure to eat all food on breakfast tray
- D. Client hair loss during morning bath
Correct Answer: A
Rationale: Nausea and vomiting can lead to metabolic alkalosis due to loss of gastric acid, making it important to report promptly to prevent acid-base imbalances.
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When performing a physical examination, what approach is most important for the nurse to use?
- A. A head-to-toe approach to avoid missing an important area
- B. The same systematic, efficient sequence for all examinations
- C. A sequence that is least revealing and embarrassing for the patient
- D. An approach that allows time to collect the nursing history data while performing the examination
Correct Answer: B
Rationale: The correct answer is 'The same systematic, efficient sequence for all examinations.' Consistency ensures thoroughness and reduces the likelihood of missing critical details.
Which of the following imbalances should the nurse check for in a pregnant client with hypertension and cardiac dysrhythmias?
- A. Metabolic acidosis
- B. Hypomagnesemia
- C. Hypernatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Hypomagnesemia is commonly associated with pregnancy-induced hypertension and can contribute to cardiac dysrhythmias. Magnesium plays a critical role in neuromuscular function and electrolyte balance.
Which nursing actions would demonstrate the nurse’s understanding of the concept of providing safe care without using restraints (select all that apply)?
- A. Placing patients with fall risk in low beds.
- B. Making hourly rounds on patients to assess for pain and toileting needs.
- C. Applying a jacket vest loosely so the patient can turn but cannot climb out of bed.
- D. Placing a disruptive patient near the nurses’ station in a chair with a seat belt.
Correct Answer: B
Rationale: Low beds, frequent checks, and strategic placement reduce risks without resorting to physical restraints.
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for
- A. laboratory tests and perioperative medications.
- B. preoperative and postoperative teaching by the nurse.
- C. psychologic support to alleviate fears of pain and discomfort.
- D. preoperative nursing assessment related to possible risks and complications.
Correct Answer: A
Rationale: Ambulatory centers often streamline processes, reducing the need for extensive laboratory tests and perioperative medications.
A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Assessing airway patency is the priority in the immediate postoperative period following a laryngectomy to ensure the client's ability to breathe. If the airway is compromised, it can lead to life-threatening complications. Pain severity (A), wound drainage (B), and tissue integrity (C) are important assessments but are secondary to ensuring the client's airway is clear and functioning properly. Prioritizing airway patency allows for prompt intervention if any issues arise, ensuring the client's safety and optimal recovery.