Nokea
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
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A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
- A. Widened pulse pressure
- B. Unilateral motor weakness
- C. Unilateral slowing of pupil response
- D. A decline in the level of consciousness
Correct Answer: D
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse should include which priority action in the plan?
- A. Monitor intake and output.
- B. Assess the tissue at the surgical site.
- C. Monitor the area for numbness or tingling.
- D. Assess the complete blood cell count results.
Correct Answer: C
Rationale: Arthroscopy provides an endoscopic examination of the joint and is used to diagnose and treat acute and chronic disorders of the joint. The priority nursing action is to monitor the affected area for numbness or tingling, which could indicate neurovascular compromise.
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
- A. Covering the back dressing with a binder
- B. Placing the infant in a head-down position
- C. Strapping the infant in a baby seat sitting up
- D. Elevating the head with the infant in the prone position
Correct Answer: D
Rationale: Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial side-lying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
- A. Identifies that the tube is draining normally
- B. Assesses the tube to locate a possible occlusion
- C. Auscultates the lungs for appropriate bilateral expansion
- D. Assists the client with frequent coughing and deep breathing
Correct Answer: B
Rationale: After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.