Nokea
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: Performing chest physiotherapy (CPT) at least two hours after meals is important to prevent potential risks such as vomiting and aspiration. This timing allows for better tolerance of the procedure and decreases the likelihood of complications. By waiting at least two hours after meals, the nurse ensures that the patient's stomach is not full, reducing the risk of regurgitation during the chest physiotherapy session. This practice promotes the safety and well-being of the patient while undergoing this treatment.
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A client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in women?
- A. Breast cancer
- B. Lung cancer
- C. Brain cancer
- D. Colon and rectal cancer
Correct Answer: B
Rationale: Lung cancer causes the most deaths in women. Despite breast cancer being the most common type of cancer in women, lung cancer is responsible for the highest number of deaths among women due to factors such as smoking, secondhand smoke exposure, and other environmental factors. It is crucial for women to be aware of the risks associated with lung cancer, even if they are non-smokers, and to take steps to reduce their risk factors through lifestyle changes and early detection methods.
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- A. Otoplasty
- B. Presbycusis
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: Presbycusis is the term that indicates that the patient has a hearing loss caused by aging. It is a type of sensorineural hearing loss that occurs gradually as a result of aging and affects the ability to hear high-pitched sounds. Otoplasty is a surgical procedure to correct the shape or position of the ears. Otalgia refers to ear pain. Tinnitus is the perception of ringing or buzzing sounds in the ears.
The LEAST helpful advice for a 10-month-old baby refusing spoon feeding is
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for child and 1 for parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer diet may not address refusal due to developmental factors.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: Steroids should not be abruptly stopped, especially in patients on long-term therapy, because higher steroid levels are needed during stress. Abruptly stopping steroids can lead to adrenal insufficiency and a life-threatening condition called adrenal crisis. Patients undergoing surgery or experiencing significant stress require higher doses of steroids to prevent adrenal crisis. It is important for healthcare providers to monitor and adjust steroid doses accordingly during stressful situations such as surgery.
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to a decrease in blood volume and blood pressure. This can cause hyperkalemia (high potassium levels) due to the lack of aldosterone, which normally helps regulate potassium excretion from the body. Additionally, clients in Addisonian crisis may experience hyponatremia (low sodium levels) rather than hypernatremia. Reduced blood urea nitrogen (BUN) and hyperglycemia would not be typical findings in acute Addisonian crisis.