Nokea
A client who had a total thyroidectomy this morning returns to the nursing care unit. How should the nurse position the client?
- A. Semi-sitting
- B. Supine
- C. Prone
- D. Sims'
Correct Answer: A
Rationale: Semi-sitting reduces neck swelling and promotes airway patency post-thyroidectomy. Supine, prone, or Sims' positions increase complications.
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A 62-year-old man who is scheduled for a total laryngectomy.
Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?
- A. We will need to learn other ways to communicate with each other.'
- B. My father will require a special kind of tube in his neck for his airway.'
- C. My husband will require a feeding tube for several months.'
- D. My dad may develop some difficulty with taste and smell after the surgery.'
Correct Answer: C
Rationale: Strategy: 'Further teaching is necessary' indicates an incorrect response. (1) will communicate in writing initially, then artificial larynx or esophageal speech (2) will require laryngectomy tube to prevent scar tissue contracture (3) correct-requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (4) common with total laryngectomy
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
- A. I'm sorry you feel that way.'
- B. I went to a fine nursing school.'
- C. You sound upset.'
- D. Please don't speak to me that way.'
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
The nurse is caring for a client with a history of heart failure who is receiving digoxin 0.125 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Fatigue and weakness.
- B. Nausea and loss of appetite.
- C. Occasional palpitations.
- D. Mild ankle edema.
Correct Answer: B
Rationale: Nausea and loss of appetite suggest digoxin toxicity, a medical emergency. Options A, C, and D are less specific or expected in heart failure.
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation