Nokea
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
- A. Altered nutrition
- B. Impaired communication
- C. Risk for injury/aspiration
- D. Altered urinary elimination
Correct Answer: C
Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.
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The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?
- A. if the tube must be capped, place the cap before deflating the cuff
- B. inflate the cuff and remove the inner cannula before capping the tube
- C. inflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
- D. deflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
Correct Answer: D
Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.
The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.
- A. Palpate vein.
- B. Cleanse skin
- C. Apply tourniquet.
- D. Perform venipuncture.
Correct Answer: C,A,B,D
Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).
A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of 6 pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: A weight gain of 6 pounds in a week suggests fluid retention, indicating possible overdosage of glucocorticoids, requiring adjustment.
An electrical fire occurs in a client's room shortly after the client returns from the recovery room after repair of a hip fracture with insertion of a prosthesis. What is the best method of removing the client from the room?
- A. Place the client in a wheelchair.
- B. Transfer the client to a gurney.
- C. Move the bed with the client on it.
- D. Do a two-person carry.
Correct Answer: C
Rationale: Moving the bed with the client on it (C) is the safest and fastest method to evacuate a post-surgical client with limited mobility during an emergency like a fire. Other methods (A, B, D) risk injury or delay.
The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
- A. Naloxone (Narcan)
- B. Ketorolac (Toradol)
- C. Acetylsalicylic acid (aspirin)
- D. Atropine sulfate (Atropine)
Correct Answer: A
Rationale: Naloxone reverses opioid overdose, critical for managing respiratory depression from morphine.