Nokea
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
- A. Monitoring the chest tubes
- B. Positioning the client on the right side
- C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
- D. Monitoring the right lung for an increase in rales
Correct Answer: D
Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.
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After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
- A. One frankfurter
- B. One ounce of ham
- C. Two slices of bacon
- D. One-fourth cup dry cottage cheese
Correct Answer: D
Rationale: Diabetic meat-exchange lists are categorized into lean-meat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange.
The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:
- A. Monitoring for arrhythmias
- B. Administering bronchodilators
- C. Monitoring for hyperglycemia
- D. Assessing for skin breakdown
Correct Answer: A
Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2 at <40%
- B. Maintain O2 at >40%
- C. Give moist O2 at >40%
- D. Maintain on 100% O2
Correct Answer: A
Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being 'bugged.' Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
- A. Protect her from suicide
- B. Enable her to develop trust
- C. Supervise her medication regimen
- D. Involve her in groups for social interaction
Correct Answer: B
Rationale: The client is suspicious and needs help to develop trust, which is basic to her improvement. Consistent nursing assignment fosters a therapeutic relationship.