Nokea
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
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Client history and assessment reveals all of these findings. Which finding supports the diagnosis of PE?
- A. Client was recently in a motor vehicle accident.
- B. Client participated in an aerobic exercise program for 6 months.
- C. Client gave birth to youngest child 1 year ago.
- D. Client was on bedrest 6 hours after diagnostic procedure.
Correct Answer: A
Rationale: The correct answer is A. Recent trauma or immobility due to a motor vehicle accident increases the risk of PE. Aerobic exercise (B), childbirth over a year ago (C), and brief bedrest (D) are less likely risk factors.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.
O2 dissociation curve shift to R) by all of the following except
- A. Increase [H+]
- B. pCO2
- C. Increase temperature
- D. Carbon monoxide
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide. Carbon monoxide does not shift the O2 dissociation curve to the right (R) because it binds to hemoglobin with a higher affinity than oxygen, causing a leftward shift (L). Increased [H+], pCO2, and temperature all shift the curve to the right by decreasing hemoglobin's affinity for oxygen.
Inflammation of the lung covering causing severe chest pain is
- A. Emphysema
- B. Pleurisy
- C. Asphyxia
- D. Hypoxia
Correct Answer: B
Rationale: The correct answer is B: Pleurisy. Pleurisy is the inflammation of the lung covering (pleura), leading to severe chest pain. Emphysema (A) is a chronic lung disease characterized by damaged air sacs. Asphyxia (C) is a condition of inadequate oxygen supply. Hypoxia (D) is a state of low oxygen levels in tissues. Pleurisy is the best fit as it directly relates to inflammation of the lung covering and severe chest pain.
Which of the following is NOT found in lung tissue?
- A. blood capillaries
- B. alveolar sacs
- C. interstitial fluid
- D. muscle
Correct Answer: D
Rationale: The correct answer is D: muscle. Lung tissue does not contain muscle tissue; instead, it is primarily composed of alveolar sacs for gas exchange, blood capillaries for oxygen exchange, and interstitial fluid for support. Muscles are not part of the structure of the lungs as they are not involved in the respiratory process. In summary, muscles are not found in lung tissue, making option D the correct choice.