Nokea
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
- A. Establish a means of communication.
- B. Prepare the bowel by administering enemas until clear.
- C. Teach the client to use an artificial larynx.
- D. Demonstrate the technique for suctioning a laryngectomy tube.
Correct Answer: A
Rationale: Establishing a means of communication is the highest priority preoperatively, as the client will lose the ability to speak post-laryngectomy.
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The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery?
- A. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
- B. The client has an oral temperature of 100.2°F and a dry cough.
- C. There are one (1) to two (2) white blood cells (WBCs) in the urinalysis.
- D. The client's current international normalized ratio (INR) is 1.
Correct Answer: B
Rationale: Fever (100.2°F) and cough (B) suggest infection, a surgical risk requiring HCP notification. Hb/Hct (A) are near normal, WBCs in urine (C) are insignificant, and INR 1 (D) is normal.
While withdrawing the suction catheter from a client's tracheostomy tube, which nursing technique is correct?
- A. Remove the catheter slowly.
- B. Push and pull the catheter.
- C. Plunge the catheter up and down.
- D. Twist and rotate the catheter.
Correct Answer: A
Rationale: Removing the catheter slowly while applying intermittent suction ensures effective secretion removal without causing trauma.
The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?
- A. Fever and crepitus.
- B. Rales and hives.
- C. Dyspnea and wheezing.
- D. Normal chest shape and eupnea.
Correct Answer: C
Rationale: Asthma exacerbation causes dyspnea and wheezing (C) from bronchoconstriction. Fever/crepitus (A), rales/hives (B), and normal breathing (D) are unrelated or incorrect.
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications?
- A. I should take two (2) puffs when I begin to have an asthma attack.
- B. I must taper off the medications and not stop taking them abruptly.
- C. These drugs will be most effective if taken at bedtime.
- D. These drugs are not good at the time of an attack.
Correct Answer: D
Rationale: Mast cell stabilizers (D) prevent asthma by stabilizing mast cells, not treating acute attacks. Puffs during attack (A), tapering (B), and bedtime use (C) are incorrect.
You're educating a patient about Warfarin (Coumadin) and how it is used to treat blood clots. Which statements by the patient require you to re-educate them about how this medication works? Select all that apply:
- A. This medication will help dissolve the blood clot.
- B. This medication will prevent another blood clot from forming.
- C. This medication will help prevent the blood clot from becoming bigger in size.
- D. This medication starts working immediately after the first dose.
Correct Answer: A,D
Rationale: Warfarin (Coumadin) does NOT dissolve blood clots. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. If the blood clot becomes bigger it may break off and travel in blood circulation. This can lead to a pulmonary embolism, heart attack, or stroke. Warfarin (Coumadin) does NOT start working immediately. It takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level. It is very common that a patient will be on Heparin while taking Warfarin until INR levels are therapeutic.