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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A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has been NPO since midnight for endoscopy
- B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
- C. The client who has end-stage renal failure and is scheduled for dialysis today
- D. The client who has gastroenteritis and is febrile
Correct Answer: D
Rationale: Step 1: The client with gastroenteritis is at risk for fluid volume deficit due to vomiting and diarrhea, leading to loss of fluids.
Step 2: Febrile state increases fluid loss through sweating.
Step 3: Combining gastroenteritis and fever exacerbates fluid loss, making this client at high risk.
Step 4: Clients A, B, and C do not have immediate factors contributing to fluid volume deficit as evident from their conditions.
Summary: Client D is at risk due to gastroenteritis and fever causing significant fluid loss. Clients A, B, and C do not have conditions directly leading to fluid deficit.
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.
Mrs. Williams asks what “presbyopia†means. The best response would be that Mrs. Williams
- A. is 'farsighted' and can see well at a distance, but her near vision is poor
- B. is 'nearsighted' and can see well when objects are close but cannot see well at a distance
- C. has distorted vision which is caused by a curvature in the eye
- D. has difficulty seeing objects that are very close because her lens is less elastic
Correct Answer: D
Rationale: Presbyopia results from decreased elasticity of the eye's lens, impairing the ability to focus on nearby objects, typically occurring with age.
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.
You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?
- A. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis
- B. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent
- C. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on an insulin drip
- D. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
Correct Answer: B
Rationale: A client with stable ABGs and ventilator dependence is less complex compared to other options, making them suitable for a step-down nurse temporarily working in ICU.