Nokea
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It facilitates the client's deep breathing
- B. It increases the client's appetite
- C. It promotes wound healing
- D. It decreases the client's anxiety
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery. Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
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A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Oral candidiasis
- B. Hypertension
- C. Increased appetite
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Oral candidiasis. Fluticasone is a corticosteroid inhaler commonly used to manage asthma. Corticosteroids can suppress the immune system locally, leading to oral candidiasis. The nurse should monitor for white patches in the mouth. Hypertension (B), increased appetite (C), and weight loss (D) are not commonly associated with fluticasone use.
A nurse explains to a client why two chest tubes are in place after a lobectomy. What is the lower chest tube for?
- A. Draining air from the pleural space
- B. Draining blood and fluid from the pleural space
- C. Providing oxygen directly to the lungs
- D. Preventing lung collapse
Correct Answer: B
Rationale: The lower chest tube after a lobectomy is to drain blood and fluid from the pleural space. This is crucial to prevent complications such as fluid accumulation, which can lead to infection or impaired lung expansion. The other choices are incorrect because: A) Draining air is usually done by the upper chest tube, C) Providing oxygen does not require a chest tube, and D) Preventing lung collapse is more related to the function of the upper chest tube in maintaining negative pressure in the pleural space.
A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. White coating in the mouth
- B. Increased heart rate
- C. Insomnia
- D. Shortness of breath
Correct Answer: A
Rationale: The correct answer is A: White coating in the mouth. This adverse effect can indicate oral thrush, a fungal infection common with inhaled corticosteroids like fluticasone. The nurse should instruct the client to report this to the provider promptly for appropriate treatment. Increased heart rate (B) and insomnia (C) are common side effects of the medication but not usually serious enough to report immediately. Shortness of breath (D) is a symptom of poorly controlled asthma and should be addressed promptly but not considered an adverse effect of the medication in this context.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the number of health care workers entering the room.
- B. Encourage the client to engage in social activities.
- C. Ensure the client receives a flu vaccine during chemotherapy.
- D. Provide daily fresh fruits and vegetables.
Correct Answer: A
Rationale: The correct answer is A: Limit the number of health care workers entering the room. This is important because immunosuppressed clients are at higher risk for infections. By limiting the number of health care workers entering the room, the nurse can reduce the client's exposure to potential pathogens. This helps to maintain a clean and controlled environment for the client, decreasing the risk of acquiring infections.
Choice B is incorrect because social activities may expose the client to a higher risk of infections from others. Choice C is incorrect because administering a flu vaccine during chemotherapy may not be effective due to the client's compromised immune system. Choice D is incorrect as providing fresh fruits and vegetables does not directly address the risk of infections from health care workers.