Nokea
A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?
- A. Hypotension
- B. Bradycardia
- C. Crackles in the lungs
- D. Dry mucous membranes
Correct Answer: C
Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients.
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Which of the following is an expected reaction from a client who has just been told by the physician that his tumor is malignant and has metastasis in to several organs?
- A. Crying uncontrollably
- B. Criticizing medical care
- C. Refusing to visit visitors
- D. Asking for additional medical consultations
Correct Answer: A
Rationale: A malignant, metastatic diagnosis often triggers grief's depression stage (Kübler-Ross), with crying as a natural emotional release. Criticism, withdrawal, or seeking consultations may reflect denial or bargaining, less immediate than sorrow. Nurses expect and support this reaction, offering empathy and presence, facilitating coping as patients process a life-altering prognosis, critical for emotional care.
A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?
- A. Obtain a random blood glucose daily.
- B. Change the IV tubing every 72 hours.
- C. Apply a new dressing to the IV site every 24 hours.
- D. Weigh the client weekly.
Correct Answer: A
Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events.
The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?
- A. Obturator
- B. Oral airway
- C. Epinephrine
- D. Tracheostomy tube with the next larger size
Correct Answer: A
Rationale: Post-tracheostomy, the obturator (A) is essential at the bedside to reinsert the tube if dislodged, ensuring airway patency. An oral airway (B) is irrelevant for tracheostomy patients. Epinephrine (C) treats allergic reactions, not routine needs. A larger tracheostomy tube (D) isn't standard emergency equipment. A is correct. Rationale: The obturator facilitates immediate tube replacement, critical in the first 72 hours before a tract forms, preventing airway loss, a priority per surgical nursing standards over other less relevant items.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a client with a fractured mandible, often wired shut for immobilization, to cut wires in emergencies like vomiting or airway obstruction, ensuring safety post-discharge. An oral airway, pliers, or tracheostomy set isn't standard for this condition wires are the focus. Nurses emphasize this precaution, teaching clients and families its use, preventing complications from restricted jaw movement during healing.
A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following interventions should the healthcare provider include?
- A. Massage the ulcer
- B. Apply a heating pad
- C. Reposition the client every 2 hours
- D. Use alcohol-based cleansers
Correct Answer: C
Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.