Nokea
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
- A. Closed chest drainage
- B. A tracheostomy
- C. A Swan Ganz Monitor
- D. Percussion vibration and drainage
Correct Answer: A
Rationale: Closed chest drainage is used post-lobectomy to remove air and fluid from the pleural space, promoting lung re-expansion.
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A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?
- A. drink orange juice to relieve discomfort
- B. drink extra milk to relieve discomfort
- C. avoid drinking from a straw
- D. rinse twice a day with antiseptic mouthwash
Correct Answer: C
Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.
Two nurses are preparing to pull a client up in the bed. Which actions by the nurses are correct in regard to safe client handling? Select all that apply.
- A. place the bed in the lowest position possible
- B. ask the client to cross her arms over her chest if she is able
- C. use a patient lifting device, such as a Hoyer lift, if needed
- D. extend the elbows out away from the body while pulling client up
- E. place the head of the bed flat or slightly Trendelenburg if the client can tolerate it
Correct Answer: B, C, E
Rationale: Asking the client to cross arms, using a lifting device if needed, and flattening the bed or using slight Trendelenburg promote safe handling. The bed should be at working height, and elbows should stay close to the body.
The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?
- A. Bradycardia and hypertension.
- B. Dry mucous membranes and tented skin.
- C. Clear, dilute urine.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.
The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
- A. The dialysate returns become cloudy in appearance.
- B. The return of the dialysate is slower than usual.
- C. A 'tugging' sensation is noted as the dialysate drains.
- D. A feeling of fullness is felt when the dialysate is instilled.
Correct Answer: A
Rationale: Cloudy dialysate indicates possible peritonitis, a serious infection requiring immediate medical intervention to prevent complications.