Nokea
A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct Answer: C
Rationale: The correct answer is C: Performing the procedure independently. This indicates readiness for discharge as it demonstrates the partner's ability to safely and effectively perform suctioning without direct supervision. Attending a class (A) and asking relevant questions (D) are important but do not necessarily indicate competence in performing the procedure. Verbally explaining the steps (B) shows understanding but does not confirm practical skill.
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In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Decreased level of serum lipids
- C. Decreased erythrocyte sedimentation rate (ESR)
- D. Increased platelet count
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream and can cause hypocalcemia due to the formation of calcium soaps. This can lead to symptoms such as confusion and tetany. The other choices are incorrect because in FES, there is no direct impact on serum lipids or ESR. Platelet count may be normal or decreased due to the consumption of platelets in the process.
Priority Decision: The nurse prepares to interview a patient for a nursing history but finds the patient in obvious pain. Which action by the nurse is the best at this time?
- A. Delay the interview until the patient is free of pain.
- B. Administer pain medication before initiating the interview.
- C. Gather as much information as quickly as possible by using closed questions that require brief answers.
- D. Ask only those questions pertinent to the specific problem and complete the interview when the patient is more comfortable.
Correct Answer: A
Rationale: The correct answer is 'Delay the interview until the patient is free of pain.' Pain can interfere with concentration and communication, making it difficult for the patient to provide accurate information. Delaying the interview ensures better quality data collection once the patient is comfortable.
A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:
- A. reinforce the dressing.
- B. continue to monitor the dressing.
- C. notify the physician.
- D. note the time and amount of blood.
Correct Answer: C
Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.