Nokea
A client who has had her jaws wired begins to vomit. What should be the nurse's first action?
- A. Insert a nasogastric (NG) tube and connect it to suction.
- B. Use wire cutters to cut the wire.
- C. Suction the client's airway as needed.
- D. Administer an antiemetic intravenously.
Correct Answer: C
Rationale: Suctioning the airway is the first action to prevent aspiration in a client with wired jaws who is vomiting. Cutting the wires is a last resort, and the other options do not address the immediate risk of airway obstruction.
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Complications associated with a tracheostomy tube include:
- A. Decreased cardiac output.
- B. Damage to the laryngeal nerve.
- C. Pneumothorax.
- D. Acute respiratory distress syndrome (ARDS).
Correct Answer: C
Rationale: Pneumothorax is a potential complication of tracheostomy tube placement due to possible injury to the lung or pleural space during insertion or maintenance.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:
- A. The prosthesis may cause a problem with the electrosurgical unit used to control bleeding.
- B. The client should not have her hip externally rotated when she is positioned for the procedure.
- C. The perioperative nurse can inform the rest of the team about the total hip replacement.
- D. There is not enough time to notify the surgeon and note this finding on the history and physical information before the procedure.
Correct Answer: A
Rationale: A hip prosthesis can conduct electricity from an electrosurgical unit, risking burns or complications. Communicating this ensures precautions are taken during surgery.
When teaching about prevention of infection to a client with a long-term venous catheter, the nurse can document that the client has understood discharge instructions when the client states which of the following?
- A. I will not remove the dressing until I return to the clinic next week.
- B. My husband or I will do the dressing changes three times per week, exactly the way you showed us.
- C. I will monitor my temperature once each weekday.
- D. I know it is very important to wash my hands after irrigating the catheter.
Correct Answer: B
Rationale: Regular dressing changes (three times per week) performed correctly indicate understanding of infection prevention for a long-term venous catheter.
The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should:
- A. Rate the client on the Glasgow Coma Scale.
- B. Administer oxygen.
- C. Check the client's baseline data.
- D. Call the surgeon.
Correct Answer: D
Rationale: Unequal pupils post-surgery suggest a neurological issue, such as increased intracranial pressure or stroke. Calling the surgeon ensures prompt evaluation and intervention.