Nokea
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in his discharge teaching? Select all that apply.
- A. Providing humidity at home.
- B. Following a bland diet.
- C. Learning how to suction himself.
- D. Having communication rehabilitation with a speech pathologist.
- E. Attending a smoking cessation program.
Correct Answer: A,C,D,E
Rationale: After a total laryngectomy, the client needs humidity to keep the airway moist, must learn to suction the airway to maintain patency, requires speech rehabilitation to learn alternative communication methods, and should attend smoking cessation to reduce further risk. A bland diet is not typically required unless specified for other conditions.
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A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and should tell the parent that the second vaccine is administered at which time periods?
- A. 3 years of age and then during the adolescent years
- B. 8 months of age and then 1 year after the initial dose
- C. 6 months of age and then 8 months after the initial dose
- D. 1 to 2 months of age and then 6 months after the initial dose
Correct Answer: D
Rationale: The vaccination schedule for an infant whose mother tests negative for hepatitis B consists of a series of 3 immunizations given at 0 months (birth), 1 to 2 months of age, and then 6 months after the initial dose. An infant whose mother tests positive receives hepatitis B immune globulin along with the first dose of the hepatitis vaccine within 12 hours of birth.
The nurse is caring for a client with a tracheostomy. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Suction the tracheostomy as needed.
- B. Clean the inner cannula daily.
- C. Change the tracheostomy ties weekly.
- D. Monitor for signs of skin breakdown.
- E. Keep the tracheostomy tube uncuffed.
Correct Answer: A, B, C, D
Rationale: Suctioning, cleaning the cannula, changing ties, and monitoring for skin breakdown are essential for tracheostomy care. Cuffed tubes are used in specific cases.
Select the legal term that is accurately paired with its description.
- A. Assault: Touching a person without their consent
- B. Battery: Threatening to touch a person without their consent
- C. Slander: False oral defamatory statements.
- D. Slander: False written defamatory statements.
Correct Answer: C
Rationale: Slander is correctly defined as false oral defamatory statements. Assault is threatening harm , battery is unauthorized touching , and libel is false written defamation .
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.
The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse should determine if the client has?
- A. Fine crackles
- B. Diminished breath sounds
- C. Stridor
- D. Pleural friction rub
Correct Answer: B
Rationale: Diminished breath sounds are typical in emphysema due to air trapping and reduced airflow. Crackles, stridor, and pleural friction rubs are associated with other conditions.