Nokea
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, 'something popped in my belly.' The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?
- A. Position the client supine with his hips and knees bent.
- B. Prepare to administer an IV infusion of 0.9% sodium chloride.
- C. Cover the wound with moist sterile gauze.
- D. Measure the client's vital signs.
Correct Answer: C
Rationale: Evisceration requires immediate covering of the wound with a sterile, moist dressing to prevent infection and tissue damage.
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A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?
- A. Blood pressure
- B. Cyanosis
- C. Nausea
- D. Petechiae
Correct Answer: C
Rationale: Subjective data are information reported by the client, such as symptoms or feelings. Nausea is subjective because the client experiences and reports it. Blood pressure, cyanosis, and petechiae are objective data that can be measured or observed directly by the nurse. Blood pressure is a vital sign, cyanosis is a physical finding, and petechiae are skin manifestations. Therefore, they are not subjective data. By understanding the distinction between subjective and objective data, the nurse can accurately assess and document the client's health status.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.
A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.