Nokea
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
- A. Provide access for wound irrigation.
- B. Promote drainage of wound exudate.
- C. Minimize development of scar tissue.
- D. Decrease postoperative discomfort.
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
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Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.
- A. Becoming increasingly short of breath at rest.
- B. Weight gain of 2 lb or more in 1 day.
- C. High intake of sodium for breakfast.
- D. Having to sleep sitting up in a reclining chair.
- E. Weight loss of 2 lb in 1 day.
Correct Answer: A,B,D
Rationale: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.
The risk for injury during an attack of Ménière'sdisease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
- A. Place your head between your knees.
- B. Concentrate on rhythmic deep breathing.
- C. Close your eyes tightly.
- D. Assume a reclining or flat position.
Correct Answer: D
Rationale: Assuming a reclining or flat position during a vertigo attack minimizes the risk of falling and injury by stabilizing the client's position.
The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
- A. Decrease in appetite.
- B. Drowsiness.
- C. Spasms of the diaphragm.
- D. Cough and shortness of breath.
Correct Answer: D
Rationale: Cough and shortness of breath are hallmark symptoms of pulmonary toxicity, indicating potential lung damage from chemotherapy and requiring immediate attention.