Nokea
An inflammatory bowel disorder in which the patient develops abdominal pain, bloody diarrhea, tenesmus (feeling of incomplete defecation), and weight loss is
- A. Crohn's disease.
- B. Diverticulitis.
- C. Ulcerative colitis.
- D. Appendicitis.
Correct Answer: C
Rationale: Ulcerative colitis typically presents with these symptoms.
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What piece of equipment should the nurse advise Mrs. Singer to have ready when her husband returns home?
- A. An electronic artificial larynx
- B. A humidifier
- C. A television
- D. A high-low bed
Correct Answer: B
Rationale: Humidifiers maintain moisture in the air, aiding breathing through the stoma.
What precaution should a nurse take to minimize the risk of death when using potassium chloride to flush a lock or central venous catheter?
- A. Use a dilute form of potassium chloride before flushing locks.
- B. Warm the potassium chloride before flushing locks.
- C. Document on the client’s chart.
- D. Ask the client to implement the instruction.
Correct Answer: A
Rationale: The correct answer is A because concentrated potassium chloride can cause cardiac arrest if injected rapidly.
When performing a physical examination, what approach is most important for the nurse to use?
- A. A head-to-toe approach to avoid missing an important area
- B. The same systematic, efficient sequence for all examinations
- C. A sequence that is least revealing and embarrassing for the patient
- D. An approach that allows time to collect the nursing history data while performing the examination
Correct Answer: B
Rationale: The correct answer is 'The same systematic, efficient sequence for all examinations.' Consistency ensures thoroughness and reduces the likelihood of missing critical details.
A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Perform range-of-motion exercises
- B. Place suction equipment at the bedside
- C. Encourage the use of an incentive spirometer
- D. Administer an expectorant
Correct Answer: C
Rationale: The correct answer is C: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications by promoting deep breathing and preventing atelectasis. A: Range-of-motion exercises do not directly prevent pulmonary complications. B: Placing suction equipment is important but does not prevent pulmonary complications. D: Administering an expectorant helps with mucus clearance but does not prevent pulmonary complications as effectively as using an incentive spirometer.
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications.
Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.