Nokea
For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
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A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
A patient with sickle cell anemia will be given supplemental oxygen and which of the following?
- A. IV fluids to adequately hydrate.
- B. Narcotic pain management when pain is severe.
- C. Transfusion of red blood cells to correct anemia.
- D. All of the above.
Correct Answer: D
Rationale: Sickle cell anemia patients often require comprehensive treatment including hydration, pain management, and blood transfusions to manage complications.
Limited health literacy may be associated with which conditions that lead to health disparities?
- A. Age
- B. Place
- C. Gender
- D. Race/ethnicity
Correct Answer: A
Rationale: Health literacy issues often correlate with age, place, race/ethnicity, language barriers, and income/education. Gender is less directly tied but still relevant in some contexts.
What physical manifestations would cue you that your client is experiencing an escalating level of anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
Which biologically based practice involves the use of scents to alter emotions and biologic processes?
- A. Herbal supplements
- B. Apitherapy
- C. Probiotics
- D. Aromatherapy
Correct Answer: D
Rationale: Aromatherapy utilizes essential oils to influence mood and biological responses.