Nokea
An adult who had a laryngectomy is ready for discharge. What question is it essential for the nurse to ask the client before discharge?
- A. How many people live in your household?
- B. Does your home have working smoke detectors?
- C. Do you cook with gas or electricity?
- D. When is your doctor's appointment?
Correct Answer: B
Rationale: Smoke detectors are critical post-laryngectomy, as impaired speech and potential airway issues increase fire safety risks, making this a priority discharge question.
You may also like to solve these questions
The nurse is caring for a client who had a right modified radical mastectomy 4 hours ago. The nurse should place the client in the
- A. high Fowler position with the right arm resting on the bed
- B. supine position with the right arm elevated on several pillows
- C. semi-Fowler position with the right arm elevated on several pillows
- D. supine position with the right arm resting on the bed
Correct Answer: C
Rationale: Semi-Fowler position with the right arm elevated promotes drainage and reduces edema post-mastectomy. High Fowler may strain the incision, and supine without elevation (B, D) increases edema risk.
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.
- A. I don't plan on eating any more frozen meals.'
- B. I plan to take my diuretic pill in the morning.'
- C. I will weigh myself at least every other day.'
- D. I'm going to look into joining a cardiac rehabilitation program.'
- E. Ibuprofen works best for me when I have pain.'
Correct Answer: E
Rationale: Ibuprofen can cause fluid retention, worsening heart failure, and requires further teaching. Avoiding frozen meals , morning diuretic , regular weighing , and cardiac rehab are appropriate.
The nurse aus.Concurrent with the above question, the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
- A. Administer an inhaled bronchodilator
- B. Check marked insertion depth of the tube
- C. Request a prescription for a diuretic
- D. Start the client on incentive spirometry
Correct Answer: C
Rationale: Crackles and diminished breath sounds in the lung bases postpartum suggest fluid overload or pulmonary edema, possibly due to prolonged labor or excessive IV fluids. Requesting a diuretic is appropriate to reduce fluid overload. Bronchodilators are for bronchospasm, checking tube depth is irrelevant without an endotracheal tube, and incentive spirometry is less urgent.
The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:
- A. $48-72$ hours
- B. 5-7 days
- C. 2-4 weeks
- D. 3-6 months
Correct Answer: C
Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect. Choices A and B are too short, and D is excessively long.
The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?
- A. Place the client in the supine position
- B. Apply counterpressure to the client's sacrum during contractions
- C. Encourage the client to remain in bed
- D. Request that the nurse anesthetist administer epidural anesthesia
Correct Answer: B
Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.