Nokea
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.
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A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She sits briefly alone with assistance.
- B. She creeps and crawls.
- C. She pulls herself to her feet with help.
- D. She stands while holding onto furniture.
Correct Answer: A
Rationale: The 9-month-old infant can sit alone for long periods. Sitting briefly alone with assistance at this age suggests a developmental delay, warranting further evaluation.
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Airway obstruction
- B. Communication impairment
- C. Pain management
- D. Infection risk
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
- A. Drinking large amounts of milk
- B. Not bearing weight on affected extremity
- C. Walking short distances 3 times/day
- D. Putting self on weight reduction diet
Correct Answer: B
Rationale: This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
- A. Impaired gas exchange related to hyperventilation
- B. Alteration in placental perfusion related to maternal position
- C. Impaired physical mobility related to fetal-monitoring equipment
- D. Potential fluid volume deficit related to decreased fluid intake
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.
The client is prescribed alendronate (Fosamax) for osteoporosis. Which instruction should the nurse include?
- A. Take the medication with a full glass of water.'
- B. Take the medication with meals.'
- C. Lie down for 30 minutes after taking it.'
- D. Take it at bedtime.'
Correct Answer: A
Rationale: Alendronate should be taken with a full glass of water on an empty stomach, and the client should remain upright for 30 minutes to prevent esophageal irritation. Meals and lying down reduce absorption.