Nokea
A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should:
- A. Encourage the client to gargle with oral lidocaine to decrease throat irritation.
- B. Monitor the client for signs of pneumothorax.
- C. Administer pain medication as needed to relieve mediastinal discomfort.
- D. Advise the client not to talk until the gag reflex returns.
Correct Answer: B
Rationale: Monitoring for pneumothorax is critical after a bronchoscopy with biopsy, as it is a potential complication due to lung puncture.
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A 70-year-old, previously well client asks the nurse, 'I notice I have tremors. Is this just normal for my age?' The best response for the nurse to make is which of the following?
- A. I wouldn't be worried because this is common with aging
- B. You should report this to the physician because it may indicate a problem
- C. You should drink orange juice when this occurs
- D. You should have your blood pressure checked when this occurs
Correct Answer: B
Rationale: Tremors in a 70-year-old are not necessarily normal and may indicate conditions like Parkinson's or medication side effects, requiring physician evaluation. Orange juice or blood pressure checks are not directly relevant.
A postoperative nursing goal for the infant who has had surgery to correct imperforate anus is to prevent tension on the perineum. To achieve this goal, the nurse should not place the neonate on the:
- A. Abdomen, with legs pulled up under the body.
- B. Back, with legs suspended at a 90-degree angle.
- C. Left side, with hips elevated.
- D. Right side, with hips elevated.
Correct Answer: A
Rationale: The abdominal position with legs tucked increases perineal tension, risking surgical site strain, unlike the other positions.
The nurse should instruct a woman taking folic acid supplements for folic acid-deficiency anemia that:
- A. It will take several months to notice an improvement.
- B. Folic acid should be taken on an empty stomach.
- C. Iron supplements are contraindicated with folic acid supplementation.
- D. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
Correct Answer: D
Rationale: Pregnancy, lactation, and oral contraceptive use increase folic acid requirements due to increased metabolic demands.
The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?
- A. Drinking from a cup and spilling little of the liquid.
- B. Raising the chest and upper abdomen off the bed with the hands.
- C. Imitating sounds that the nurse makes.
- D. Crying loudly in protest when the mother leaves the room.
Correct Answer: A
Rationale: Drinking from a cup with minimal spilling is advanced for a 7-month-old, who typically lacks such fine motor control.
The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
- A. Do you often need help with food shopping?
- B. Let's discuss how we can solve this problem.
- C. Do you have any support systems for shopping?
- D. I wish I could but I don't have time to run errands.
Correct Answer: B
Rationale: The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and long-term solutions to the problem. In options 1 and 3 the nurse asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is inappropriate while failing to address the client's problem.