Nokea
A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
- A. providing opportunities for questions and talking about the client's concerns.
- B. providing distractions such as reading or watching television.
- C. assuring the client that everything will be all right.
- D. reminding the client that the surgery is not as extensive as the client's past surgery.
Correct Answer: A
Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.
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What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.
18. Melatonin’s use is based on scientific evidence. The patient with which problem would benefit from melatonin?
- A. Sleep problems
- B. Mild depression
- C. High cholesterol
- D. Benign prostatic hyperplasia
Correct Answer: A
Rationale: Melatonin is scientifically supported for addressing sleep problems (option A), such as insomnia or jet lag.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.'
- B. I eat fruit three times a day.'
- C. I don't drink fluids after 4 P.M.'
- D. I don't like to take enemas.'
Correct Answer: C
Rationale: Restricting fluid intake after 4 P.M. can contribute to dehydration and constipation, making this statement indicative of the need for further education on proper hydration practices.
A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.
Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.