Nokea
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Hold the breath as the cuff is being re-inflated
- C. Take a deep breath as the nurse deflates the
- D. Exhale deeply as the nurse re-inflates the cuff cuff
Correct Answer: D
Rationale: The correct instruction for the client when removing secretions above the cuff of a tracheostomy tube is to exhale deeply as the nurse re-inflates the cuff. By having the client exhale deeply during cuff inflation, it helps to prevent aspiration of secretions or air into the lungs. This action also helps in securing an airtight seal around the tracheostomy tube before the normal breathing is resumed. It is crucial to promote the safety and prevent complications in clients with a tracheostomy tube, especially post partial laryngectomy.
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Although the etiology of hepatoblastoma is unknown, there are many associated risk factors for development of hepatoblastoma EXCEPT
- A. Beckwith-Wiedemann syndrome
- B. familial adenomatous polyposis syndrome
- C. prematurity
- D. Hepatitis C
Correct Answer: D
Rationale: Hepatitis C infection is not a recognized risk factor for hepatoblastoma.
A nurse has determined that a newborn's respiratory breathing is within a normal range. How should the nurse document this finding?
- A. Irregular, abdominal, 30 to 60 breaths/min
- B. Regular, abdominal, 25 to 35 breaths/min
- C. Regular, noisy, 35 to 45 breaths/min
- D. Irregular, quiet, 45 to 55 breaths/min
Correct Answer: B
Rationale: A newborn with normal respiratory breathing would typically exhibit regular breathing patterns, with abdominal movements indicating effective diaphragmatic breathing. The normal respiratory rate for a newborn is considered to be 25 to 35 breaths per minute. Therefore, documenting the newborn's respiratory breathing as "Regular, abdominal, 25 to 35 breaths/min" would accurately represent a normal finding.
A nurse needs to assess a client who is undergoing urinary diversion. Which of the ff assessment is essential for the client?
- A. The client's knowledge about the effects of the surgery on his sexual function
- B. The clients medical history of allergy to iodine or seafood
- C. The clients knowledge about the effects of the surgery on his nervous control
- D. The clients occupational and environmental health hazards
Correct Answer: C
Rationale: The essential assessment for a client undergoing urinary diversion is the client's knowledge about the effects of the surgery on his nervous control. Urinary diversion is a surgical procedure that involves redirecting urine flow from the bladder to a new exit point in the body due to bladder cancer, birth defects, or other medical conditions. Understanding the effects of the surgery on nervous control is crucial as it can impact the client's ability to control urination and bowel movements post-surgery. Educating the client about these effects will help in managing expectations and in planning for any necessary adjustments to their lifestyle and daily routine. It is important for the nurse to assess the client's level of understanding and provide appropriate education and support regarding nervous control changes that may result from the procedure.
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.