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A problem for the patient with a new laryngectomy would be feelings of isolation due to being unable to communicate verbally. Which nursing intervention is appropriate?
- A. Complete care quickly.
- B. Provide a pad and pencil or magic slate.
- C. Refrain from conversations with the patient to reduce stress level.
- D. Offer books or jigsaw puzzles for entertainment.
Correct Answer: B
Rationale: Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.
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Which nursing intervention is for a patient, age 40, who is diagnosed with active tuberculosis?
- A. Place the patient in drainage and secretion precautions.
- B. Place the patient in acid-fast bacillus (AFB) Isolation Precautions.
- C. Maintain the patient in enteric isolation.
- D. Place the patient in any Isolation Precautions.
Correct Answer: B
Rationale: If TB is suspected, place the patient in acid-fast bacillus (AFB) Isolation Precautions immediately.
In which way do leukotriene modifiers reduce the symptoms of asthma?
- A. By drying up mucus
- B. By causing bronchodilation and anti-inflammation effects
- C. By suppressing cough
- D. By liquefying mucus
Correct Answer: B
Rationale: Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes.
Which patient assessment indicates the most severe respiratory distress?
- A. Nasal flaring, symmetrical chest wall expansion, SaO2 88%
- B. Abdominal breathing, SaO2 97%
- C. Substernal retraction, SaO2 84%
- D. Substernal retraction, SaO2 90%
Correct Answer: C
Rationale: Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.
The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. Which symptoms will the patient likely exhibit?
- A. Edema of the lower extremities and extended neck veins due to hypertension of the pulmonary circulation.
- B. A dry hacking cough and chest pain due to constriction of the pulmonary vein.
- C. Hypertension and a headache related to pulmonary hypertension.
- D. Unlabored respiration and cyanosis around the mouth.
Correct Answer: A
Rationale: COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites.
A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. Which action should be the nurse's initial intervention?
- A. Report signs to the charge nurse.
- B. Elevate head of bed and administer oxygen.
- C. Prevent patient from excessive coughing.
- D. Increase IV flow rate.
Correct Answer: B
Rationale: When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the health care provider should be notified, but only after the patient is positioned and oxygenated.