Nokea
A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient's NG tube and initiates oral feedings. Which of the following statements should the nurse make? Which statement should the nurse make post-laryngectomy?
- A. You should have no trouble swallowing fluids.
- B. It is no longer possible for you to choke on or aspirate food.
- C. I will add a thickener to your liquids to prevent aspiration.
- D. Tuck your chin when you swallow so you won't choke.
Correct Answer: D
Rationale: The correct answer is D: "Tuck your chin when you swallow so you won't choke." After a laryngectomy, patients have altered anatomy that can affect swallowing. Tucking the chin helps close off the airway during swallowing, reducing the risk of choking. This technique directs the food towards the esophagus instead of the trachea, minimizing the risk of aspiration. Choices A, B, and C are incorrect because they do not address the specific swallowing precautions needed post-laryngectomy. Choice A assumes normal swallowing function, which may not be the case. Choice B is inaccurate as aspiration can still occur post-laryngectomy. Choice C is not specific to the patient's individual needs and may not be necessary.
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Medication Administration Record
• 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
• 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
• 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
• 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6°C (101.5°F)
• Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
Nurses' Notes
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
Physical Examination
• Heart Rate: 88/min
• Respiratory Rate: 18/min
• Blood Pressure: 115/55 mm Hg
• Temperature: 36.4°C (97.5°F)
• Oxygen Saturation: 96% on 2 L via nasal cannula
• General Behavior: Drowsy but arouses easily, somewhat lethargic
• Pain Level: Rated as 6 on a scale from 0 to 10
• Bowel Sounds: Hypoactive in all four quadrants
• Urinary Output: Clear yellow urine from indwelling catheter
• Knee Dressing: Dry and intact with no drainage
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.Exhibits Complete the following sentence by selecting the most appropriate action from the choices below:
The nurse should first:---------------------,followed by--------------------------------------
- A. Administer additional morphine for pain management
- B. Reposition the client for comfort
- C. Assess the area where the restraint is to be placed on the client
- D. Pad the client’s wrists under the restrain
- E. Ensure the client’s call light is within reach
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Postoperative pain; Parameter to Monitor: Pain level, Client comfort.
Rationale: After a knee arthroplasty, pain management is crucial for the client's comfort and recovery. Administering additional morphine (A) addresses postoperative pain. Repositioning the client (B) is important to prevent complications such as pressure ulcers. Assessing the area for the restraint (C) and padding the client's wrists (D) are not immediate priorities. Ensuring the call light is within reach (E) is important but not the first action to take.
A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain. The nurse notes that the patient's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? What condition is indicated by paradoxical chest movement?
- A. Flail chest
- B. Hemothorax
- C. Atelectasis
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest is characterized by a segment of the rib cage that moves independently due to multiple rib fractures. The paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration, is a classic sign of flail chest. This occurs due to the loss of stability in the rib cage, leading to ineffective breathing mechanics.
Incorrect answers:
B: Hemothorax - This is the accumulation of blood in the pleural cavity, which would not cause paradoxical chest movement.
C: Atelectasis - Atelectasis is the collapse of lung tissue, which would not result in paradoxical chest movement.
D: Pneumothorax - Pneumothorax is the presence of air in the pleural space, which typically causes chest pain and shortness of breath but does not result in paradoxical chest movement.
A nurse in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a client who has nausea and a prescription for metoclopramide intravenously every 8 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which explanation should the nurse provide?How does metoclopramide relieve nausea?
- A. The medication relieves nausea by promoting gastric emptying.
- B. The medication works by relaxing gastric muscles.
- C. The medication works by decreasing gastric acid secretions.
- D. The medication enhances gastric emptying.
Correct Answer: A,D
Rationale: The correct answers are A and D. Metoclopramide relieves nausea by promoting gastric emptying, which helps move food through the stomach faster. This action reduces the feeling of fullness and discomfort, ultimately alleviating nausea. Additionally, enhancing gastric emptying helps prevent reflux, which can contribute to nausea. Choices B and C are incorrect because metoclopramide does not work by relaxing gastric muscles or decreasing gastric acid secretions. These mechanisms do not directly address the issue of delayed gastric emptying, which is the primary reason for nausea relief with metoclopramide.
A nurse is caring for a patient who is postoperative following a cesarean section. Which of the following findings should the nurse report to the provider? Which finding post-cesarean should the nurse report?
- A. Lochia serosa
- B. Fundus firm at the umbilicus
- C. Mild cramping
- D. Foul-smelling vaginal discharge
Correct Answer: D
Rationale: The correct answer is D: Foul-smelling vaginal discharge. This finding indicates a possible infection, which is crucial to report to the provider for prompt intervention. Foul odor may indicate endometritis or other postoperative complications.
A: Lochia serosa is a normal finding post-cesarean.
B: Fundus firm at the umbilicus is a normal finding post-cesarean, indicating proper involution.
C: Mild cramping is common post-cesarean due to uterine contractions as it returns to its pre-pregnancy size.