Nokea
A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to:
- A. Prevent postoperative bladder infection.
- B. Reduce the number of intestinal bacteria.
- C. Decrease the potential for postoperative hypostatic pneumonia.
- D. Increase the body's immunologic response to the stressors of surgery.
Correct Answer: B
Rationale: Oral neomycin is administered preoperatively to reduce intestinal bacteria, decreasing the risk of infection during bowel surgery. It does not target bladder infections, pneumonia, or immune response directly. CN: Pharmacological and parenteral therapies; CL: Apply
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Which of the following is a potential complication following cataract surgery? Select all that apply.
- A. Acute bacterial endophthalmitis.
- B. Retrobulbar hemorrhage.
- C. Rupture of the posterior capsule.
- D. Suprachoroidal hemorrhage.
- E. Vision loss.
Correct Answer: A,B,C,D,E
Rationale: Potential complications after cataract surgery include acute bacterial endophthalmitis (infection), retrobulbar hemorrhage (bleeding behind the eye), rupture of the posterior capsule (lens capsule tear), suprachoroidal hemorrhage (bleeding in the choroid), and vision loss due to these or other complications.
Which intervention supports a client with expressive aphasia?
- A. Speak loudly.
- B. Use written instructions.
- C. Provide a communication board.
- D. Ask complex questions.
Correct Answer: C
Rationale: A communication board supports communication for clients with expressive aphasia.
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
- A. Decrease secretions.
- B. Instruct the client in caring for the tracheostomy.
- C. Relieve anxiety related to the tracheostomy.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
The nurse is conducting a focused assess of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:
- A. Paralytic ileus.
- B. Gastric distention.
- C. Hiatal hernia.
- D. Curling's ulcer.
Correct Answer: D
Rationale: Burn injuries increase stress and metabolic demand, predisposing clients to Curling's ulcer, a stress-related gastric ulcer, due to reduced mucosal protection.