Nokea
An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?
- A. Vertigo.
- B. Bell's palsy.
- C. Hypoventilation.
- D. Loss of gag reflex.
Correct Answer: C
Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.
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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.
A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.