Nokea
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
- A. Surfing
- B. Scuba diving
- C. Parasailing
- D. Swimming
Correct Answer: B
Rationale: Scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
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A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
The parents of a child with cystic fibrosis discuss nutritional requirements and the need for vitamin supplements with the nurse. The nurse explains that it is necessary to give daily supplements of vitamins A, D, E, and K because:
- A. Children with cystic fibrosis require vitamin supplements because their metabolism is increased.
- B. Children with cystic fibrosis do not eat a well-balanced diet.
- C. Children with cystic fibrosis do not absorb fat-soluble vitamins.
- D. Children with cystic fibrosis have an increased excretion of water-soluble vitamins.
Correct Answer: C
Rationale: Cystic fibrosis impairs fat absorption, leading to deficiencies in fat-soluble vitamins (A, D, E, K), necessitating supplementation.
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
The nurse is caring for a client with organic brain syndrome in a long-term care facility.
Which of the following actions by the nurse is BEST?
- A. Encourage the client to verbalize his feelings regarding the relationship with his family that initiated his nursing home placement.
- B. Help the client to express his favorite pastimes and the type of activities that he enjoys.
- C. Orient the client to the present time and assist him to be alert and oriented when his family comes to visit.
- D. Direct conversation toward assisting the client to reminisce and talk about important past events in his life.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) may not remember who or where he is (2) not as important as answer choice #4 (3) even with orientation, the client soon forgets (4) correct-geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss
Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
- A. Increases the cardiac output
- B. Decreases the cardiac output
- C. Indicates a cardiac tamponade
- D. Increases diaphoresis and the likelihood of hypothermia
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.