Nokea
A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional (RN, LPN/LVN, nurse practitioner, nutritionist) should be assigned to address the following topics?
- A. Explain screening exams and diagnostic testing for common cancers.
- B. How to plan a balanced diet and reduce fats and preservatives.
- C. Prepare a poster on the seven warning signs of cancer.
- D. How to practice breast or testicular self-examinations.
Correct Answer: A
Rationale: RNs are best suited to explain complex medical procedures like screening exams and diagnostic tests, while other topics may involve collaboration with nutritionists or nurse practitioners.
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Which triage assessment prioritizes the client’s need for treatment as the need to be seen now?
- A. Delayed
- B. Immediate
- C. Minimal
- D. Expectant
Correct Answer: B
Rationale: The correct answer is B because immediate triage indicates the client requires urgent treatment.
To evaluate a teaching plan implemented for a patient being discharged, what should the nurse do?
- A. Document the plan
- B. Report to the head nurse that teaching was done
- C. Compare learning outcomes with objectives
- D. Ask his family what he has learned
Correct Answer: C
Rationale: Comparing learning outcomes with objectives ensures the teaching plan was effective.
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
How would you confirm a client has heard instructions if they nod yes to everything?
- A. Ask them to repeat the instructions back
- B. Provide written instructions
- C. Observe their behavior during implementation
- D. All of the above
Correct Answer: D
Rationale: Multiple methods ensure understanding and retention of the information.
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
- A. having a heart attack.
- B. wanting attention from the nurses.
- C. suffering from complete upper airway obstruction.
- D. hyperventilating.
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.